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LIBRARY OF THE 
UNIVERSITY OF ILLINOIS 
AT URBANA-CHAMPAIGN 


AC 
6 O/ 


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4 “ 


it 


MIND AND ITS DISORDERS 


MIND 
AND ITS DISORDERS 


A TEXT-BOOK FOR STUDENTS AND 
PRACTITIONERS OF MEDICINE 


BY 


Vimo LOW Deki MED bO RCP. 


PHYSICIAN non lexrat DISEASES TO ST. THOMAS’S HOSPITAL 
LECTURER ON MENTAL DISEASES TO ST. THOMAS’S HOSPITAL MEDICAL SCHOOL 
LATE EXAMINER IN PSYCHOLOGY AND MENTAL DISEASE TO THE UNIVERSITY OF LONDON 


HONORARY TREASURER OF THE BRITISH PSYCHOLOGICAL SOCIETY, 
AND OF THE BRITISH PSYCHO-ANALYTICAL SOCIETY 


LATE RESIDENT PHYSICIAN AND MEDICAL SUPERINTENDENT OF 
BETHLEM ROYAL HOSPITAL 


FIFTH EDITION 
WITH ILLUSTRATIONS 


PHILADELPHIA 
P. BLAKISTON’S SON & CO. 
1926 


First Edition 


Second Edition 


Third Edition 
Fourth Edition 
Fifth Edition 


Printed in England 


November, 1908 
August, 1912 
August, 1919 
September, 1921 
September,, 1926 


ay Ke 

9 eRe. (n 
hl »wO 
<Q sco 
L)® / ( Ce OQ 


ieee nee ho shir FIP RH EDIRION 


For the present edition the work has been thoroughly revised 
throughout. The following are, perhaps, the chief changes. 
Under the heading of Treatment of General Paralysis in the fourth 
edition I gave a critical digest of the manifold methods of intra- 
thecal medication. As these methods have all been nowadays 
replaced by two more recent and successful ones—viz., the try- 
parsamide and the malarial treatment—I have described these 
methods in some detail to the exclusion of the above critical 
digest. 

A chapter on Encephalitis lethargica has been included. . 

I am again indebted to Mr. W. H. Gattie, K.C., for revising 
the chapter on the Insane and the Law, and to Dr. Eric Graham 
Howe, of Bethlem Royal Hospital, for his scrupulously careful 
and conscientious revision of the proof-sheets. I also wish to 
express my gratitude to my wife for making herself responsible 
for the Index, which will therefore be found much more reliable 


than that in the fourth edition. 
W. H. B. STODDART. 
Harcourt HOousg, ° 
CAVENDISH SQUARE, W.1. 
July, 1926. 


oO 

rt 

Ww Vv 
J 


- 


@#09975 


PREFACE TO THE FOURTH EDITION 


Tue flattering reception accorded to the last edition having 
exhausted the stock much earlier than was anticipated it has not 
been possible to make, in the general scheme of this manual, 
certain radical changes contemplated in the desire to orientate 
my readers among the enormous mass of contemporary research 
in this field, mainly by Professor Freud and his followers. 

One of the many results of this new knowledge is that the 
classification of mental disorders is temporarily in a state of 
flux, and I have again effected some rearrangement of the 
chapters in Part III. to show how our classification stands at the 
moment. 

My views regarding neurasthenia require that this malady be 
classified as a psychoneurosis, and not as a neurosis.. Since going 
to press it has become obvious to me that exophthalmic goitre is 
also a psychoneurosis, and not a true neurosis. Exophthalmic 
goitre is really a variety of anxiety hysteria, and should be 
described under that heading. It follows that the only true 
neurosis is the anxiety neurosis. 

The researches of Ferenczi, Pierce Clark, and others, into the 
mysteries of epilepsy have demonstrated this disease to be a 
psychosis and it is now described under that heading. More- 
over, we have to recognize that alcoholism and drug habits are 
psychoses, differing from those maladies caused by the excessive 
use, or rather abuse, of alcohol or drugs. These are intoxications; 
therefore alcoholism and the alcoholic insanities are described in 
different parts of the volume. Indeed, Chapter XV. would have 
been more in its proper place as Chapter XIII. 


Vii 


Viil PREFACE TO THE FOURTH EDITION 


In view of the fact that there is a thread of psycho-analysis 
running right through the book, the short chapter assigned to 
this subject has been entirely rewritten. 

When the manual was first published, my endeavour was to 
induce the reader to think neurologically of mental processes, 
normal and morbid, and to study them from a neurological point 
of view. Since that time, however, owing to the psychological 
researches of Freud, and previously Janet and others, it has been 
found that we gain a clearer insight into mental processes when 
we approach them from a purely psychological standpoint; but, 
although I am a loyal disciple of Professor Freud, I am not one 
of those who would therefore abandon other methods of research 
into mental processes. I am sure that Freud himself would 
adopt the same attitude; for in spite of his triumph in this branch 
of medicine, he is too great a man to deride other methods of 
investigation. © 

The neurological and psycho-analytical points of view are 
so different that any attempt to describe both in the same 
volume, much more to correlate them, is rather liable to present 
an almost unavoidably futuristic picture. Mental and physical 
factors are even more intimately related than is commonly - 
supposed. Physiological processes and physical diseases almost 
invariably have their mental concomitants or sequele; and 
mental processes, both normal and morbid, may originate gross 
organic changes. We are only just beginning to learn that the 
endocrines are a most important factor in neurosis, psycho- 
neurosis and psychosis, and the time is not far distant when it 
may be possible for a manual of psychiatry to be written from 
an endocrinologist’s point of view without opposing the psycho- 
analytical trend of thought in the very least. Not yet, however, 
has this aspect of the subject been evolved sufficiently for me to 
refer to it in the text, except here and there, and quite super- 
ficially. 


I wish to express my best thanks to Dr. Clement Lovell, 


PREFACE TO THE FOURTH EDITION 1X 


Pathologist to Bethlem Royal Hospital, for preparing specimens 
of the Gold-Sol reaction for the plates in Appendix B, and 
passing them for press, to Dr. Brushfield of the Fountain 
Hospital for some new photographs for the chapter on Mental 
Deficiency, and especially to Dr. John Rickman for his careful 
and conscientious revision of the proof-sheets and for valuable 


suggestions. 
Weed. pb. STODDART, 
Harcourt House, 
CAVENDISH SQUARE, W. I, 
July, 1921 


We Ose le Fe NS: 


Jeri kell Jk. 
NORMAL PSYCHOLOGY. 


CHAPTE Ral 
INTRODUCTION. 
Mentation. Psychological Methods. The Neuron Theory. Syn- 


apses. Neurokyme. Scheme of the Nervous System. Con- 
sciousness and Sensation. Unconscious Mentation - - 
si Om Oe ae 0 al a 
SENSATION. 


Its Attributes and Modes. Unconscious Sensations - - - 


CHAPTER III. 
PERCEPTION AND IDEATION. 

Their Similarities and Differences. Their Physical Basis. Space- 
perception. Time-perception. Conception. Ideational Type. 
Unconscious Percepts - - = - - - 

CHAPTER IV. 
ASSOCIATION OF IDEAS. 


Compound Ideas. Associations by Similarity and Contiguity. Cog- 
nition. Recognition. Memory and Forgetting. Imagination. 
Judgment and Reasoning. Unconscious Associations - - 

CHAPTER V. 
APP ECT EON. 

Tones of feeling. Emotions, Passions, Moods and Temperaments. 

Their Physical Basis. Unconscious Emotion - - - 
CHAPTER VI. 
ACTION. 


Reflex, Instinctive, Voluntary and Automatic. The Reaction Ex- 
periment. Unconscious Action - . Z : 


xi 


13 


30 


47 


54 


65 


xl CONTENTS 


CHAPTER VII. 
ATTENTION, 
Its Laws and Varieties. Voluntary, Instinctive, Reflex and Auto- 


matic Attention - = 4 . : 3 


. 


CHAPTER VIII. 
FATIGUE, SLEEP AND DREAMS. 
Muscular Fatigue. Contracture. Intellectual Fatigue. Sleep, 
Dreams and Hypnosis - - - - - 
CHAPTER IX. 
THE SENTIMENTS: 
Esthetic, Moral and Intellectual. Modes of Belief - - - 


CHAPTER X. 
LANGUAGE, 


Gesture. Pantomime. Wordsas Symbols of Mentation - - 


CHAPTER Al 
LE EGO: 


Its Development. The Super-Ego. Personal Differences. The 
Unity of Mentation - - - ~ Es 


PART II. 


PSYCHOLOGY OF THE INSANE. 
CHAPTER 1; 
DISORDERS OF SENSATION. 

Cutaneous Analgesia. Diminution of other Sense-modalities. 
Hyperesthesia. Erroneous Localization. Hysterical Disturb- 
ances of Sensation - : s . . = 

CHAPTER II. 
DISORDERS OF PERCEPTION. 


Imperception. Ideational Inertia. Physical Basis of Imperception. 
‘“Systematized Anesthesia.’? Hallucinations and _ Illusiors. 
Their Physical Basis and Psychology. Synesthesize - - 

CHAPTER III. 
DISTURBANCES OF THE ASSOCIATION OF IDEAS. 


Retardation and Acceleration. Disorders of the Normal Sequence of 
Ideas. Disorders of Memory - - - ‘ : 


PAGE 


86 


92 


104 


109 


II2 


118 


124 


140 


CONTENTS 


CHAPTER IV. 
DISORDERS OF THE EMOTIONS. 


Excess and Defect of Emotional Reaction - - - - 


CHAPTER V. 


ABNORMALITIES OF ACTION (DISORDERS OF 
CONDUCT). 


Apraxia.’ Disorders of the Instincts; their Rise and Fall. Erro- 
neous Instincts. Disorders of Speech and Writing. Disorders 
of Attention - - - - - - - 


CHAPTER VI. 
ERRONEOUS JUDGMENTS (DELUSIONS). 


sane and Insane Delusions. Insight. Disorders of Sentiment. 
Changed Personalities. Sex and Station. The Comprehen- 
siveness of Mental Disorder - - - - - 


CHAPTER VII. 
PSYCHO-ANALYSIS. 


The Unconscious. Complexes and Conflicts. Repression. Sub- 


limations and _ Reactions. Psychosexual Development. 
Technique. Free Association. Interpretation of Dreams. 
Transference - - - - - - - 


CHAPTER VIII. 
ANOMALIES OF THE SEXUAL INSTINCT. 


Masturbation. Sexual Inversion. Sadism and Masochism. The 
Role of the Senses - = - ‘4 a ae 


PAR L EL: 
MEN PAL DISEASES: 


CHAPTER I. 
THE CAUSATION OF MENTAL DISORDER. 


Endogenous and Exogenous Causes . - - - 


CHAPTER II. 
THE PHYSICAL STIGMATA OF DEGENERATION. 


The Cranium. Atavistic Anomalies. The Pinna. The Palate, 
The Jaw. The Limbs. General Abnormalities - . 


xiii 


PAGE 


148 


152 


165 


176 


Ig! 


198 


ZEE 


X1V CONTENTS 


NEUROSIS. 


CHAPIER sit; 
PAGE 
THE ANXIETY NEUROSIS 219 


THE PSYCHONEUROSES. 
CHAPTER IV. 


NEURASTHENIA 224 
CHAPTER V. 
AY SLERTA: 
Conversion Hysteria. Fixation Hysteria. Anxiety Hysteria. 
Mental Characteristics. Hysterical Insanity. Exophthalmic 
Goitre - - - - - - - - 230 


CHAPTER VI. 
THE OBSESSIONAL NEUROSIS: 


Compulsive Thoughts, Fears and Impulses_~ - - = - 252 


THE PSYCHOSES. 


CHAPTER VII: 


MANIACAL-DEPRESSIVE INSANITY (INTERMITTENT 
AND PERIODIC PSYCHOSES). 


Melancholia. Mania. Anergic Stupor. Terminal Dementia. 
Psychopathology. - General Management - - - 260 
CHAPTER VIII. 
PARANOIA. 


Eccentrics and Egocentrics. Communicated Insanity - - 304 


CHAPTER IX. 
DEMENTIA PRHACOX. 


Its Obscure Pathology. Catalepsy and Catatonia. Simple 
Dementia Precox. Hebephrenia. Katatonia. Dementia 
Paranoides - - r : : Z eas 

CHAPTER X. 
PARAPHRENIA. 


Paraphrenia Systematica, Expansiva, Confabulans and Phantastica 
Paraphrenia ab hallucinatione - - - - 343 


CONTENTS XV 


CHAPTER XI. 
PRIER PSY AND EPILEPTIC INSANITY. 


PAGE 


The Epileptic Character. Epileptic Convulsions and their ‘“‘ Equiva- 
lents.”’ Epileptic Dementia - - - - - 349 


CHAPTE ROXIE 
ALCOHOLISM - - = 372 


CHAPTER XIII: 
SOME OTHER DRUG HABITS. 


Morphinism. Cocainism. Chloralism. Paraldehydism. Chronic 
Sulphonal Poisoning. Cannabis Indica Poisoning. Belladonna 
and Atropine Poisoning. EtherInebriety. Plumbism - - 376 


TOXIC INSANITY. 


CHAPTER XIV. 
ACUTE CONFUSIONAL INSANITY. 
Mental Exhaustion and Intoxication. Synaptic Rebuff - - 388 


CHAPTER XV. 
ALCOHOLIC INSANITIES. 


Etiology. Physiological and Pathological Inebriation. Delirium 
Tremens. The Polyneuritic Psychosis. Subacute Alcoholic 
Insanity. Chronic Hallucinatory Insanity. Alcoholic Para- 
noia. Alcoholic Dementia - - - - - 399 


CHAPTER XVI. 


MENTAL DISORDERS ASSOCIATED WITH PRIMARY 
DISEASE OF THE ENDOCRINE ORGANS. 


The Thyroid (Myxcedema and Cretinism). The Pituitary Body. 
The Suprarenals. The Pineal. The Sex Glands - - 419 


ORGANIC INSANITIES. 


CHAPTER XVII. 
GENERAL PARALYSIS (DEMENTIA PARALYTICA). 
Clinical Varieties. Modern MethodsofTreatment. Morbid Anatomy 431 


XV1 CONTENTS 


CHAPTER XVIII. 


MENTAL DISORDERS ASSOCIATED WITH COARSE 
CEREBRAL LESIONS. 


PAGE 
Increased Intracranial Pressure. Cerebral Poisoning by Products 


of Neural Disintegration. Focal Symptoms - - - 463 


CHAPTER XIX. 


ENCEPHALITIS LETHARGICA, EPIDEMIC ENCEPHALITIS 
OR PLEEPY SICKNESS. - - : - - - 4068 


CHAPTER AX. 
CHRONIC CORTICAL ATROPHY. 


Arteriopathic and Senile Dementias. Presbyophrenia. Alzheimer’s 
Disease - = - 7 5 ss = 473 


CHAPTER XXI. 


MENTAL DISORDER ASSOCIATED WITH CERTAIN OTHER 
NERVOUS MALADIES. 


Chorea. Huntington’s Chorea. Paralysis Agitans - - - 484 


CHAPTER XXII. 


MENTAL DISORDERS OCCURRING IN ASSOCIATION WITH 
VISCERAL DISEASE. 


Prolonged Pain. Pulmonary and Cardiac Disease. Blood-Pressure, 
Uremia. Diabetes. Gout - - - - - 488 
CHAPTER XXIII. 
IDIOCY AND IMBECILITY. 
(AMENTIA OR MENTAL DEFICIENCY.) 


Symptoms. Varieties and Degrees. Binet-Simon Tests - - 492 


CHAPTER XXIV. 
COMBINED INSANITIES - - 515 


CHAPTER XXV. 
MEIGNEGD JIN SAIN, Joyo) - - 518 


CHAPTER XXVI. 


SOME DISEASES TO WHICH THE INSANE ARE ESPECIALLY 
TTAB LE, 


Phthisis. Asylum Dysentery. Cutaneous Affections - - 521 


CONTENTS . XVil 


CHAPTER XXVII. 
PAGE 
CASE-TAKING - - - 532 


CHAPTER XXVIII. 
GENERAL TREATMENT. 


Asylum and Single Case. Contraband. Bed. The Physician, 
Occupation. Seclusion and Mechanical Restraint. Food and 
Feeding. Hydrotherapy. Medicines. Prevention of Suicide: 
Visits and Letters from Friends - - - - 539 


CHAPTER XXIX. 
THE INSANE. AND THE LAW. 


The Board of Control. Establishments for the Insane. Reception 


Orders and Certificates. Judicial Inquisition. Transfer. 
Escapes. Legal Capacities and Responsibilities of the Insane. 
Schedule Forms - - - - - - - 550 


APPENDIX A. 
METHODS OF STAINING THE NERVOUS SYSTEM - 575 


APPENDIX B. 
EXAMINATION OF THE CEREBRO-SPINAL FLUID - - 580 


INDEX : : : . : : : - 586 


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ee er US ALON 


FIG, PAGE 
I. Two NorMAL BETz CELLS : - Coloured Plate facing 5 
2. A Motor CELL FROM THE PRECENTRAL GYRUS - : 6 
3. SCHEME OF THE NERVOUS SYSTEM - - Plate facing 10 
4. BLIND Spot DIAGRAM - - - = 5. 23 
5. THE CEREBRAL CORTEX - - - - - eS 2 
6-8. To ILLUSTRATE “‘ IDEATIONAL RIVALRY ”’ - - - 34 

g-12. To ILLUSTRATE ‘‘ IDEATIONAL UNITY AND THE PERCEPTION 
OF DEPTH” - - - - - - 35, 36 

13-17. To ILLUSTRATE THE MUSCULAR ELEMENT IN VISUAL SPACE- 
PERCEPTION - - a : 37, 38 
18, 19. METRONOME DIAGRAMS (TIME-PERCEPTION) - - = 42 
20. SLEEP CHART (AFTER E. W. SCRIPTURE) - ~ =e 07, 
21. EXAMPLES OF ANALGESIA IN THE INSANE ~ - - 119 
22. APRAXIC PSEUDOGRAPHIA - - . - - 160 
23. APRAXIC IDEATIONAL INERTIA IN WRITING - - TOt,) LOZ 
24. SENILE WRITING - ~ - - - - 163 
25. INCIDENCE OF INSANITY - - - Plate facing 203 
26. DEFORMITIES OF THE PINNA - - - a aa 213 
27, 28. H@mMaToMA AURIS) - - - - “ - 214 
29. Casts OF DEFORMED PALATES - - - Plate facing 215 

30. SIMIAN THUMB OF A PATIENT SUFFERING FROM DEMENTIA 
PRAECOX - - . - - - - 216 

31. NoRMAL THUMBS, FLEXED TO SHOW THE INTERNAL ROTATION 
OF THE TERMINAL PHALANGES ~ - - - 217 

32. SIMIAN HAND OF A PATIENT SUFFERING FROM DEMENTIA 
PRECOX - - - - - - ay, 
33. PERIODIC INSANITY - - ~ - Plate facing 262 
34. MELANCHOLIAC WRINKLING - - - . - 266 
35, 30. MELANCHOLIAC HANDSHAKES - - - - 267 

37. FACSIMILE OF TEST-TYPES USED IN THE INVESTIGATION OF 
MELANCHOLIA - - - - Plate facing 268 
38. SLEEP CHART IN MELANCHOLIA - - - eats, 
39. AGITATED MELANCHOLIA - - . : a egy: 
40. MELANCHOLIAC GAIT - - - - - wee 27 
41. ACUTE MANIA - - - - - - - 284 
42. ACUTE MANIA - - - ~ - . - 285 
43. MANIACAL HANDSHAKE - - - - ~ - 286 
44. ManiacAL HANDSHAKE - - = a a. Ly ~ 287 


LIST OF ILLUSTRATIONS 


. SLEEP CHART IN MANIA - - - . - 
. HYPOTONIA IN ANERGIC STUPOR - - = = 
. ANALGESIA IN A CASE OF TERMINAL DEMENTIA - - 
. AGE-INCIDENCE OF DEMENTIA PR#COX - = = 
. SIMIAN HANDS OF DEMENTIA PRACOX - - - 
. DEMENTIA PR#COX: ERECTION OF THE HAIR - - - 
. NORMAL MUSCLE CURVE - - - - - 
. DEMENTIA PRHCOX CURVE - - -" - - 
. DEMENTIA PR#HCOX: WRINKLED FOREHEAD - - - 
. DEMENTIA PR#COX: FLEXIBILITAS CEREA . - - 
. KATATONIAC ANTIC - - - - - - 


57. DEMENTIA PR&cOX HANDSHAKES - . - - 


. PSEUDOGRAPHIA - = = & - - 
. HEBEPHRENIAC SECLUSIVENESS - - - - - 
. DEMENTIA PRZCOX GROUP - : : A i 
. IMMATURE BETZ CELLS IN DEMENTIA PRACOX 


Coloured Plate facing 


. ANALGESIA IN THE CASE OF ACUTE CONFUSIONAL INSANITY - 
. PART OF A LETTER BY A WELL-EDUCATED PATIENT SUFFERING 


FROM ACUTE CONFUSIONAL INSANITY - - - 


. Betz CELL IN ASTATE oF AXONAL REACTION Coloured Plate facing 
. WRITING IN SUBACUTE ALCOHOLIC INSANITY - . - 


67. SPORADIC CRETIN - - - = é - 


. LETTER BY A GENERAL PARALYTIC - - - - 
. CORTICAL VESSEL OF A GENERAL PARALYTIC, SHOWING TYPICAL 


PLASMA CELLS - = = ‘ > : 


. GLIA OR SPIDER CELL FROM THE CEREBRAL CORTEX OF A GENERAL 


PARALYTIC - = - 2 = ~ 


. SPIDER CELLS IN THE INNERMOST CORTICAL LAYER FROM A 


CASE OF CHRONIC INSANITY - - - - 


. FILM MADE FROM THE CEREBRO-SPINAL FLUID OF A GENERAL 


PARALYTIC - - - Coloured Plate facing 


. SENILE WRITING - = = S, s 2 
. SENILE BRAIN - = . = a a 
. GENETOUS IMBECILES (BROTHER AND SISTER) - - - 
. HyDROCEPHALIC IMBECILE - = : 2 : 


GROUP OF MONGOLIAN IMBECILES - : oe is 


. MICROCEPHALIC IDIOT - - : x > be 
. HYPERTROPHIC IMBECILE - ms 2 2 = 
. EPILOIA - - = es “ * 3 
. BINET-SIMON TEST: PAIRS OF LINES~ - = - = 


‘iG ES - « A * of 
“5 fy », « MiIssInc PARTS - a - A 
» 5 tL OLDED (Paper - 3 4 E 
» 5 eo CARD ws : - 4 x8 


. PROLONGED BATH - = = z . - 
. (a and b). Gotp-Sot REAcTION Coloured Plates following 


PAGE 
290 
297 
299 
318 
319 
a21 
321 
322 
322 
325 
327 
329 
pe 
333 
336 


340 
390 


393 
410 
412 
424 
443 


457 
458 
459 


462 
476 
478 
498 
499 
500 
501 
503 
504 
507 
508 
509 
511 
511 
544 
584 


ERRATA 


Page 303, first line, for “ paralysis,” read “psychoanalysis.” 


Page 326, seven lines from bottom, for “cataleptic,” read 


catatonic.” 


66 


xe 


< x * 45 
9 eae 


SS Fn eet 
peal pee 


MIND AND ITS DISORDERS 


Baul. I: 
NORMAL PSYCHOLOGY. 


CHAPTER I- 
INTRODUCTION. 


“ It ts even so—Nature is nowhere accustomed more openly to display her 
secret mysteries than in cases where she shows traces of her workings apart 
from the beaten path ; nor is there any better way to advance the proper practice 
of medicine than to give our minds to the discovery of the usual law of Nature 
by careful investigation of cases of raver forms of disease. For it has been 
found, in almost all things, that what they contain of useful or applicable is 
hardly perceived unless we are deprived of them, or they become deranged in 
some way.’’—WILLIAM HARVEY.* 


THE medical curriculum is so arranged that during the first two 
or three years the student learns about the structure and func- 
tions of the normal human body so as to prepare him for the 
study of disease when he gets into the hospital wards or sub- 
sequently into practice. There is, however, a curious and 
remarkable omission in that he receives no instruction in psy- 
chology or the study of the normal mind to prepare him for the 
study of mental disorders which he will subsequently encounter 
among his patients. It therefore falls to the lot of a treatise of 
this nature to supply the omission by giving a short preliminary 
exposition on normal psychology. 

The study of the normal mind can be approached from many 
aspects; one of these the student will have encountered in the 
course of his ordinary medical studies—viz., psychological 
physiology. This consists of the study of the central nervous 
system in general, and of the brain in particular—its structure, 
histology, and physiology, and all that is included under the 
term “‘neurology’’. He will have learned something about 
Loeb’s tropisms, Pavloff’s conditioned reflexes, and a relation- 
ship between certain endocrine glands and the emotions. There 


* Quoted from Sir Archibald E. Garrod’s “ Harveian Oration,” 1924, 
I 


2 MIND AND ITS DISORDERS 


‘ 


is also “ physiological psychology’, which endeavours to reduce 
specific mental processes to laboratory form and to examine 
them by means of various ingenious types of apparatus. We 
shall have to allude to this branch in further detail, because of 
its utility for descriptive purposes. : 

When, however, we come into practical relationship with the 
minds of individuals in the world of reality—as, for example, 
in the dealing with patients—we find that physiological psychology 
does not help us very much; we therefore have to approach our 
subject from yet another angle, and to study the mind #er se, 
paying little or no regard to its physical basis or to physiological 
principles. Leaving out of account the speculative psychology 
of the last century, there are many other ways of investigating 
the mind. We may, for example, approach it from an evolu- 
tionary standpoint by examining the behaviour of animals and 
endeavouring to arrive at some conclusion about what goes on 
in their minds (animal psychology) ; or we can make observations 
of normal human children in order to trace the way in which 
the mind develops in a normal person (child psychology). Then 
there is “applied psychology’’, or the study of the mind in 
certain practical relationships—for example, educational psy- 
chology, industrial psychology, including vocational psychology, 
esthetic psychology, social psychology, and medical psychology, 
which last is of the greatest importance to the readers of this 
treatise. The titles explain themselves; but, in whichever 
territory any particular psychologist may be working, he will 
find it helpful to take an occasional peep over the wall to see 
what his neighbours are doing. 

Now it has just been hinted that normal psychology should 
form a part of the medical curriculum in order to prepare the 
student for the study of mental disorder; but in medical 
psychology greater advances have been made by investigating 
mentally afflicted patients than by exploring the psychology 
of normal individuals. Indeed, psycho-analysis, which plays an 
important rdle in medical psychology and will subsequently be 
described, is a science which was entirely developed from the 
study of such patients whose mentation deviated from the 
normal. 

There is nothing new in this principle. The paragraph at the 
head of this chapter shows that it was recognized by the great 
Harvey more than two centuries ago; yet, so long as physiology 
remained a purely academic science, it was not of any great 
value to clinical medicine. It is only in recent years, during 


PHYSICAL BASIS OF MENTATION 3 


which physiology has taken the facts of clinical medicine and 
pathology into account, that it has been of service to clinical 
medicine. This principle is also illustrated in other natural 
sciences, é.g., in astronomy new stars have been revealed by 
observing the deviation of other stars from their expected course; 
in chemistry new elements have been detected in an analogous 
way. Argon was discovered by noting that there were certain 
discrepancies in the weights of the gases of the atmosphere. 
There is, however, no necessity to labour the point; in all branches 
of knowledge we learn about the normal by studying the ab- 
normal. The discoveries having been made, the student of any 
particular science is taught ordinary natural processes before 
proceeding to those which are anomalous or unusual; but, for 
reasons which will appear later, it is often found that it is better 
_ for even beginners in medical psychology to learn about mental 
mechanisms from the abnormal, every patient being a new 
research de novo, and subsequently to ascertain to what extent 
those mechanisms occur in a normal person. 

Until the present century psychology suffered from too much 
importance being attached to sensation, which was considered 
_ to be the essential unit of mental experience, while affection was 
regarded as a mysterious sort of side show, disturbing to sensa- 
tion and perception. But when we come to think of it, what 
determines a particular line of conduct is not any particular 
sensation or percept, however complex it may be, but the affective 
tone of pleasure or displeasure which accompanies it. This can 
be observed even in the very lowest micro-organisms. The 
amoeba, for example, moves towards a morsel of food, but away 
from anything that is harmful to it. A plasmodium will move 
towards a drop of water and ultimately immerse itself in it, but 
move away from a drop of brine, thus exhibiting an elementary 
form of affective tone or desire accompanying the crude sensa- 
tions aroused by the water, brine, food etc. Loeb and his school 
look upon human behaviour as a complex of similar tropisms, 
and psycho-analytical investigation in man has shown the unit 
of mental experience to bea wish. Of course, many of our wishes 
are frustrated by external circumstances, or even by an opposing 
wish in the mind of the same individual. Such thwarting of our 
wishes is naturally disappointing; but, so long as the process is 
conscious and recognized, it does little orno harm. In the course 
of this volume, however, it will be shown that some of these 
conflicting desires may be unrecognized and therefore uncon- 
scious, and that they are then liable to give rise to all sorts of 


4 MIND AND ITS DISORDERS 


complications, sometimes mental disorder or even physical 
disease. 

On the other hand, physical disease may give rise to mental 
disorder in all sorts of ways, either by its direct. effect on the 
mind or by causing nutritional disturbance of or definite organic 
changes in the brain. Throughout the ages a great deal of 
discussion has taken place respecting the relationship between 
the mind and the brain. To us as physicians it does not matter, 
but to us as philosophers it may matter very much indeed. 
Broadly speaking, there are two main schools of thought. 
According to the first—the spiritwalistic—the material brain is 
pervaded by an immaterial something, the mind or soul, which 
is held responsible for all men’s thoughts and actions. The 
adherents to this view are divided into two sub-classes: (a) Those 
who regard the connection between body and soul as a Divine 
arrangement (occasionalists or phenomenalistic parallelists) ; and 
(6) those who regard the mind or soul as the principle of life and 
thought (animists, Aristotelians, monists). According to the 
second or interactionist school, the mind is regarded as a process 
or function having its physical basis in the brain (epiphenomenal- 
ism); mental and physical mechanisms proceed simultaneously 
without having any direct relationship with one another (psycho- 
physical parallelism), or perhaps a more accurate way of ex- 
pressing this view would be to say that a certain causal relationship 
is recognized, but that the nature of the relationship is not known. 
In general, this is the view adopted throughout the present 
manual, but an attempt is made here and there to demonstrate 
the connection between various mental and physical processes, 
and to correlate them so far as our present knowledge will 
allow. 

The medical student approaching the study of mental disease 
for the first time will already have acquired some considerable 
knowledge of general medicine and pathology. This he will find 
essential for the comprehension of his new subject. It is also 
important that he should have a sound knowledge of the anatomy 
and physiology of the nervous system, and this he will have 
acquired in the course of his ordinary medical studies. Recent 
investigations would appear to show that in the near future a 
knowledge of biochemistry and the physiology of the endocrine 
glands is likely to play an important réle in the study of mental 
disease. For the present it will be necessary to study the nervous 
system from a fresh aspect, including the way in which it sub- 
serves the function of mentation. 


TRE LIRSARY 
OF THE 
WNIVERSITY OF ILLINOIS 


Fic. 1.—I wo NorRMAL BETZ CELLs. 


Showing the arrangement of the Nissl bodies (chromato- 
plasm—tigroid substance)—in large cubes or oval spindles 
which extend into the dendrites but not into the axon (%) or 
the eminence from which this arises. The nucleus is situated 
centrally and is clear. (X600.) [Negative kindly lent by 
Dr. John Turner of Brentwood Asylum. } 


To face p. 5 


THE NEURON 5 


We may now regard as accepted that the nervous system 
consists of myriads of isolated* neurons, each of which has 
potential connections with other neurons, by which nervous 
impulses may be transmitted from one neuron to another. In- 
going nervous impulses are conveyed from the peripheral sense- 
organs to the central nervous system in general and, so far as we 
as students of insanity are concerned, to the cerebral cortex in 
particular; while outgoing nervous impulses are conveyed from 
the central nervous system in general and, so far as we as students 
of insanity are concerned, from the cerebral cortex in particular 
to the muscles of the head, trunk and limbs. 

A neuron or nerve-cell is, then, to be regarded as a mechanism 
for the transmission of nervous impulse from one part of the 
organism to another, mostly to and from the cerebral cortex, 
which is itself nothing more or less than a mass of neurons. 
Each neuron consists of a cell-body or perikaryon, an axis- 
cylinder or axon, and one or more protoplasmic processes called 
dendrons. A nervous impulse enters by way of one of the 
dendrons and passes through the cell-body to the axon, whence 
it is transmitted to the dendron of another neuron. 

If the cell-body be stained with methylene blue (Nissl’s 
method), it is found to contain in its middle a large unstained 
nucleus, in whose centre is a deeply stained nucleolus (sometimes 
two). When stained in this way (vide Appendix A), it may be 
observed, moreover, that the substance of the cell-body consists 
of an unstained fibrillar or reticular matrix (achromatoplasm) 
enclosing a large number of roughly triangular stained granules 
(chromatoplasm, tigroid substance or Nissl bodies). The fibrils 
of the achromatoplasm can frequently be traced through the 
cell-body from the dendrons to the axon, or from one dendron to 
another; hence it is inferred that the function of this substance 
is to convey nervous impulses from one part of the neuron to 
another, and it has for this reason been also named the kineto- 
plasm. And from the fact that the chromatoplasm gradually 
disappears as the result of fatigue, it is inferred that this sub- 
stance serves the function of nutriment to the cell. It has 
accordingly received the alternative name of trophoplasm. 

The protoplasmic processes or dendrons are, as a rule, branched 
and beset with large numbers of minute twigs or thorns, like so 
many pinheads protruding at right angles to these processes. 
It has been demonstrated by Lugaro that these twigs, which 


* The fact that protoplasmic continuity between neurons occurs occasion- 
ally, but rarely, is of purely academic interest. 


6 MIND AND ITS DISORDERS 


are called gemmules, are more or less amoeboid, since they are 
protruded during sleep and retracted during activity.* Demoor, 
however, held the opposite view. Little differentiation of struc- 
ture of the dendrons can be determined under the microscope. 
The axis-eylinders or axons are longitudinally fibrillated and, 
so far as they remain within the confines of the grey matter, 


Fic. 2.—A Motor CELL FROM THE PRECENTRAL Gyrus (SEMI- 
DIAGRAMMATIC). 


a, Axon with collaterals; b, dendron showing gemmules; c, moniliform 
(degenerate) dendron from which the gemmules have disappeared. 


unprotected; but as soon as they reach the white matter, they 
are enclosed within myelin sheaths, which appear to be the con- 
ductors of electrical currents. In their course the axons give 


* This observation was made on dogs in the following way: The animals 
were prepared, and cannulz# were introduced into their carotids. The 
dogs being severally in a state either of activity or somnolence, a quantity 
of Cox’s fluid was run into the cannule, and the neurons thus fixed in situ. 
Sections of the cerebral cortex were sybsequently cut and examined, and 
it was found that the gemmules were retracted in those animals which were 
in a state of activity at the time of the experiment, while in the somnolent 
animals they were in protrusion. These observations, however, still await 
confirmation. 


SYNAPSES 7 


off branches at right angles to tlfmselves; these are known as 
collaterals, and are destined to convey impulses to the proto- 
plasmic processes of other neurons. 

Transmission of the Nervous Impulse.—It is probably to be 
inferred from Lugaro’s observations (vide supra) that, when a 
nervous impulse passes from onnee uron, a, through another, £, 
to. a third, y, the collaterals of a cause certain gemmules on the 
dendrons of 8 to react and to protrude. Contact being thus 
ensured between a and #, the nervous impulse passes up one of 
8’s dendrons through its cell-body and axis-cylinder to one of 
its collaterals. Here reaction again occurs: one of y’s gemmules 
is in turn protruded and the impulse passes on toy. During the 
process other gemmules of the neurons concerned are retracted. 

The sites of contact between neurons are called synapses, and 
it is probable, as McDougall has pointed out, that they play a 
most important rdle in physical processes. I have just said 
that, by the protrusion of gemmules, contact is made between 
one neuron and another; but, as a matter of fact, it is probable 
that contact is incomplete and that a very thin layer of inter- 
neuronal tissue always intervenes and offers a certain amount 
of resistance to the passage of a nervous impulse across the 
synapse. 

There is considerable evidence in favour of this resistance. 
(1) The ordinary rate of conduction of a nervous impulse along 
a nerve-fibre is about 50 metres per second, and there is no 
reason to suppose that any delay occurs in its transmission 
through the cell-body of a neuron; indeed, such evidence as is 
available negatives the suggestion. But when the impulse has 
to be transmitted across a synapse, as in ordinary reflex action, 
there is delay in the transmission amounting to one-hundredth 
of a second—time enough for the impulse to have travelled 
another third of a metre if the nerve-tract were continuous 
instead of interrupted. (2) The rate of transmission of an 
impulse along a nerve-fibre is constant and independent of the 
intensity of the stimulus; whereas an increase in the intensity 
of a stimulus increases the rapidity with which a reflex action 
takes place. This shows that there is a certain amount of 
resistance to stimuli, which is overcome less readily when these 
are weak than when they are strong and is to be conceived as 
occurring at the synapse. (3) If a series of sensory stimul,, 
which are individually insufficient to provoke a reflex, be applied 
in rapid succession to a reflex-provoking area, reflex action 
results. This, again, is indicative of synaptic resistance. 


8 | MIND AND ITS DISORDERS 


Other characteristics of syfaptic transmission, as shown by 
the study of reflex action, are susceptibility to fatigue and to 
the influence of drugs, necessity for good circulation in the 
neighbourhood of the synapse, and irreversibility of direction of 
the nervous impulse (law of forward conduction). The trans- 
mission of impulses along nerve-trunks, on the other hand, is 
influenced but little by drugs or by interference with the circu- 
lation, is practically insusceptible to fatigue, and may take place 
in either direction. 

For the present I will allude to only two more characteristics 
of reflex action, viz., (a) after-discharge and (bd) facilitation. 
(a) If a stimulus be applied to a nerve-trunk connected with a 
muscle, the muscle ceases to contract almost synchronously with 
cessation of the stimulus; but if contraction of the muscle be 
induced reflexly (through a reflex arc), irregular contractions of 
the muscle continue for some time after cessation of the stimulus — 
(after-discharge). (b) If a reflex be capable of being stimulated 
through two or more receptive (sensory) areas, and if subliminal 
stimuli be given to these (stimuli which are insufficient indepen- 
dently to provoke the reflex), reflex contraction occurs when both 
areas are stimulated together, the cumulative action of the two 
subliminal stimuli being sufficient to induce a nerve-current in 
the “ final common path ”’ (facilitation). For example, a sudden 
sound and a flash of light, if of sufficient intensity, are each 
capable of inducing reflex closure of the eyelids. This reflex 
closure will also take place if two such stimuli, neither of which 
is sufficiently intense independently to provoke the reflex, occur 
simultaneously or even with a short interval of time between 
them. Another example of facilitation which has a closer 
bearing on the mental processes presently to be considered is the 
following: if a spot be found upon the cerebral cortex of a dog, 
the stimulation of which produces a movement which can also 
be produced reflexly, and if subliminal stimuli be applied simul- 
taneously both to the spot on the cortex and to the receptive 
area of the reflex, movement will result, although either stimulus 
alone is insufficient to induce the movement. Inter alia this 
explains why reaction to a stimulus takes place more quickly 
when attention is directed to the idea of movement than when 
it is directed to the stimulus. 

To explain these phenomena McDougall has conceived every 
neuron to be charged with a certain quantity of nerve-force, 
which he calls “‘ neurin”’ or “‘ neurokyme’”’, much in the same way 
as a Leyden jar is charged with electricity. The effect of any 


HIERARCHY OF THE NERVOUS SYSTEM 9 


stimulus to a neuron is to set free in it a further quantity of 
neurokyme. When a neuron thus becomes surcharged, the 
excess of neurokyme overflows at its synapses. Naturally the 
overflow is more likely to take place at some synapses than at 
others, especially at those which are in constant use and where 
overflow has taken place before. Considerations such as these 
give us a peep at the physical basis of “‘ habit’. 

When one neuron receives from another an overflow of neuro- 
kyme, it tends in its turn to become surcharged and to overflow 
into other neurons, and so on. The ultimate result is either 
diffusion of nerve-force if the quantity of neurokyme in the 
nervous system happens to be at a low ebb or, more commonly, 
there is a final overflow into motor tracts and, conformably to 
the law of conservation of energy, contraction of muscle results, 
neurokyme being converted into work. 

Mind.—When we speak of mind we mean that faculty or 
function in us by which we become aware of our surroundings 
and their distribution in space and time, by which we experience 
feeling, emotions, and desires, and are able to attend, to re- 
member, to reason and to decide. 

In the succeeding pages it will be shown that, concomitantly 
with affective tone, sensation is an essential attribute of conscious 
organisms and that all the more complex mental functions are 
derivable therefrom. In the course of evolution, sensation, 
which is presumably an attribute of even the lowest unicellular 
organisms, is believed by the author to exist in the individual cells 
of the highest multicellular organisms, such as man. Every cell 
is regarded as having sensation, the neuron being the most 
sensitive of all, sensation therein being aroused by a surcharge 
of neurokyme. Sensations of cells of the other highly organized 
tissues (skin, retina etc.) are represented again and again on the 
following scheme. 

Scheme of the Nervous System.—Sensations aroused at the 
periphery are first represented in bipolar cells, the dendrons of 
which are usually devoid of gemmules. They are next repre- 
sented in cell-stations, whence there is a divergence of paths of 
conduction, one path going cerebrumwards, and the other cere- 
bellumwards (vid the restiform body). It is significant that no 
such station occurs in the olfactory path, which has no con- 
nection with the cerebellum. Following up the cerebro-petal 
path, we find that sensations are next represented in groups of 
cells which may be classed together under the heading of “ basal 
ganglia ’’, the next representation being in the sensory so-called 


IO MIND AND ITS DISORDERS 


“centres ’’ of the cortex cerebri, which, together with the motor 
area in front of the fissure of Rolando, have received the name of 
projection centres. The highest representation of sensation is 
in the remainder of the cerebral cortex, which was divided by 
Professor Flechsig into four great association centres. P 

A question, which naturally arises in this connection, is ““ How 
far down the nervous system do consciousness and apprehended _ 
sensation, or rather their physical bases, extend ?’”’ This has 
partially been answered by Head and Holmes in an illuminating 
paper published in Brain (November, 1911). According to these 
investigators, it would appear that sensations requiring little 
discrimination, such as pain, pressure, tickling, scraping and 
vibration, are registered, perhaps finally, in the optic thalamus; 
while sensations requiring discrimination, such as warmth, cold, 
the sense of position and the estimation of weight, size and con- 
sistence, are registered, perhaps exclusively, in the projection 
areas of the cerebral cortex. And it may be inferred from 
analogy that elementary sensations of light, sound, odour and 
flavour, may be registered in homologous basal gangla, while 
the discrimination of various sense qualities takes place in 
corresponding projection areas. 

The diagram will help to elucidate the above points. The 
connections figured between the projection and association areas 
are in accordance with Flechsig’s researches, and it will be 
observed that the cortex cerebri is a colony of neurons, having 
very numerous intercommunications. It is a colony of the most 
sensitive cells of the organism. The combined sensation of 
these neurons constitutes the consciousness of the colony, and 
this is none other than the consciousness of the organism. This 
combined consciousness is aroused whenever resistance at the 
synapses is overcome by the escape of a surcharge of neurokyme 
from one set of neurons to another. 

A little consideration of the phenomena of unconsciousness 
will show the importance of sensation in establishing mental life. 
When a person faints, his skin becomes numb and finally anzs- 
thetic; his vision grows indistinct till all is dark; sounds grow 
more distant; there is, perhaps, a momentary sound of rushing 
waters, then all is silent. When a patient is anesthetized, 
he loses sensation and is therefore unconscious; his mental 
phenomena and sensations disappear part passu. 

In the unconsciousness of deep sleep no sensations are per- 
ceived and, at times, it requires a strong sensory stimulus to wake 
the sleeper, the conscious mind being in abeyance. The new- 


en tne ene nn ee ee ee eee eee, 
. 


ROLANDIC 
AREA 


NUCLEI 

GRACILIS 
AND 

CUNEATUS 


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AUDITORY 
NUCLEUS 


ASSOCIATION 
AREAS 


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LIMBIC PROJECTION O 
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BULB THALAMUS] GANGLIA 


STATIONS OF 
DIVERGENCE TO 
CEREBELLUM 


PAPILLAE 


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GANGLIA SPIRALE GENICULATE CELLS 
GANGLIA 
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CONES LINGUAL ERIPHERY 
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FIG. 3.—SCHEME OF THE NERVOUS SYSTEM. 


The dotted line surrounds the neurons subserving the function of the 
superficial reflexes. 


(a) Peripheral nerves. 
pharyngeal. (d) Pyramidal tract. 
nerve. 
(7) Optic nerve and tract. 
(m) Olfactory tract. 


(b) Olfactory nerves. 


(h) Glossopharyngeal and pars intermedia. 
(k) Mesial fillet. 


(c) Chorda tympaniand glosso- 
(e) Posterior columns. (g) Auditory 
(2) Lateral fillet. 
(¢) Centrum ovale. 


To face p. 10 


He P78 RY 
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MIVERSITY OF ILLUS 


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UNCONSCIOUS MENTATION si i 


born infant, whose sensations are as yet but feebly developed, 
spends the greater part of its time in sleep. In the coma of 
epilepsy, apoplexy, intracranial pressure, diabetes, ureemia etc., 
the criterion of unconsciousness is lack of response by the patient 
to pin-pricks, shouts, electric batteries or any other form of 
powerful stimulus which the ingenuity of the physician can 
devise. If none of these stimuli evoke a response, the patient’s 
mentation is considered to be in abeyance; for the time being 
he has no mind. In the case of children deprived of the senses 
of hearing and vision from birth there results the condition 
known as “ idiocy by deprivation of the senses ”’; they experience 
fewer sensations than healthy children and are therefore mentally 
deficient. 

Finally we have Strumpell’s classical case of the patient who 
suffered from universal anesthesia, bilateral deafness and uni- 
lateral blindness. All knowledge of the outside world came to 
him through his sound eye and, when this eye was closed, he 
went to sleep; in other words, he lost consciousness. 

Our general conclusion is, therefore, that sensation is essential 
to consciousness and, in our further considerations, it will be 
shown that mind, with all its higher functions of memory, dis- 
crimination, will, reason etc., may be evolved from sensation, 
which is indissolubly associated with affective tone, without 
invoking the aid of a “‘ thinking principle’’, “‘ apperception ”’, or 
any other form of higher intellectual spontaneity. 

It will be objected that this theory does not explain the origin 
of sensation and that it involves the adoption of the hylozoistic 
view that sensation is an attribute of matter. Arguments are 
by no means wanting that the hylozoistic view is correct, but 
whether sensation is an attribute of matter or not is a meta- 
physical question, which probably can never be settled and 
would be out of place in a practical handbook; but the author 
believes that the above mode of thinking of the nervous system 
in its relation to mind will at least prove helpful to the psychol- 
ogist and the student of insanity. 


Unconscious MENTATION. 


On the opposite page the question was raised “‘ How far down 
the nervous system does consciousness extend ?”’ and it was 
partially answered. The question referred to consciousness of 
the organism as a whole, but there is reason to believe that 
groups or colonies of neurons in subservient lower portions of 


IZ MIND AND ITS DISORDERS 


the nervous system have something akin to consciousness of 
their own. Pavloff’s conditioned reflexes, for example, support 
this view. This consciousness forms no part of the consciousness 
of the whole organism, and the nervous functions of such neuronal 
colonies are therefore regarded as unconscious. 

There are, however, many more unconscious nervous operations 
than these, including some whose physical basis undoubtedly 
lies in the cerebral cortex. In the following chapters we shall 
have occasion to refer to sensations, percepts, ideas, desires and 
even judgments, which are not registered in conscious memory; 
they are unconscious. There are, moreover, many incidents and 
situations which, although remembered for a time, are later 
completely forgotten. These also constitute a large part of the 
unconscious mind. ) 

In due course such groups of phenomena will be considered in 
detail. They are mentioned now for the purpose of stating that 
nothing is known of the physical basis of the unconscious. 
Hitherto it has been studied by psychological methods only. It 
would be easy to hazard a conjecture that some ideas remain 
unconscious because certain gemmules refuse to protrude, and 
thus to make the contact necessary to arouse conscious memory 
or to discern an analogy between synaptic resistance and the 
unconscious resistance to the revival of certain memories; but 
this would be mere guesswork. For the present we must 
admit our total ignorance of the difference between the physical 
processes underlying subconscious and unconscious mental 
phenomena and those subserving conscious thought. 

Purely psychological research, however, has furnished ample 
evidence that the unconscious part of the mind contains far 
more psychical material than the conscious, which is merely the 
small perceptible part. In this sense the mind has been com- 
pared with an iceberg, nine-tenths of which is submerged while 
only one-tenth 1s open to direct observation. The submerged 
portions of both the mind and the iceberg can be investigated 
by very difficult soundings and probings and by observation of 
the behaviour of the perceptible portions under unusual con- 
ditions. Methods of penetrating the deeper recesses of the 
mind will be set forth in subsequent chapters. 


GEA helt 
SENSATION. 


WuAT sensation is we do not know. Some psychologists seek to 
explain it by the principle of “‘ relativity ’’, which recognizes that 
every sensation is experienced in relation to some other sensation, 
that we are conscious only as we are conscious of change. Black 
can only be felt in contrast to white or, at least, in distinction 
from a paler or deeper black; a sound can only be sensed as con- 
trasting with other sounds or with silence. If all the stimuli at 
any given moment were to continue ad infinitum without change, 
sensation, and therefore consciousness, would disappear. 

All this we are prepared to admit, given sensation ; but this 
doctrine, which is known as the “ Law of Relativity’”’, begs the 
whole question. If change of stimulus is all that is required to 
arouse sensation, every stone in the road must have sensation, 
exposed as it is to an enormous variety of stimuli. Indeed, 
although its supporters would not admit it, the doctrine is hylo- 
zoistic at bottom; it assumes that sensation is an attribute of 
matter, a view with which I am disposed to agree, but to discuss 
it would lead us into the domain of metaphysics. 

When we think, we think of something, of some object in our 
present or past environment; and we think of it in terms of the 
sensations aroused by the object. If, for example, we have an 
idea of a cigar, the idea is composed of revived visual sensations 
(brown image of characteristic shape), olfactory sensations 
(aroma), perhaps auditory and gustatory sensations (crackling 
when rolled between the finger and thumb, saltish taste), tactile 
sensations, etc. Such sensations are the elemental processes of 
which consciousness is composed, and are associated with physical 
processes in definite bodily organs. 

A simple sensation, as the word is used here, is a pure abstrac- 
tion. Nobody ever experienced the colour red, the tone C or 
the temperature 100°, and nothing else: these are but attri- 
butes of objects in the environment of the individual who sees 
the colour, hears the tone or feels the temperature. It is, how- 
ever, useful, and indeed necessary, to study such simple sensa- 

13 


I4 MIND AND ITS DISORDERS 


tions in the abstract before proceeding to the consideration of 
higher mental functions. 

Sensations may have four attributes—quality, intensity, dura- 
tion and extent. The quality of a sensation depends upon 
the specific nature of the peripheral sense-organ and associated 
sensory nerves, by the stimulation of which the sensation is 
aroused (eye, ear, tongue or Schneiderian membrane) and upon 
the nature of the stimulus to the sense-organ. All forms of 
stimulation of the optic nerve (electrical, mechanical or thermal) 
give rise to a sensation of light and to no other kind of sensation. 
All forms of stimulation of the auditory nerve give rise to a 
sensation of sound and to no other kind of sensation, and so 
forth. All highly specialized nerve-tracts have their own specific 
qualia. On the other hand, a red-sensation is different from a 
blue-sensation, because there is a difference in the nature of the 
stimulus to the retina, depending upon the different wave-lengths 
of the two kinds of light. In the domain of hearing, a C-sensa- 
tion is different from a D-sensation on account of the difference 
in the nature of the stimulus to the organ of Corti, depending on 
the difference in the rate of vibration of the air in the two cases. 
Similarly a sweet-sensation is different from a salt-sensation, an 
eau-de-Cologne sensation from a white-rose sensation, and so 
forth. These are differences in the quality of sensation. 

By the intensity of a sensation we mean that attribute by 
which one sensation is stronger or weaker than another. The 
sweetness of saxin is more intense than the sweetness of sugar, 
but the quality of the sensation is the same in the two cases. 
When a tuning-fork is struck, the resulting sound is at first more 
intense than subsequently when the fork begins to ring off; but 
the quality of the sound remains the same. Similarly one light 
may be more intense than another of the same kind, and one 
odour more powerful than another, although both may be of the 
same quality. 

By the duration of a sensation is meant the length of the period 
during which it is experienced; and by its extent is meant the 
amount of space over which it spreads; e.g., the colour red may 
occupy half the visual field or a sensation of pain two square 
inches of the forearm. On the other hand, certain sensations 
(olfactory, gustatory and auditory) cannot be said to have any 
extent. 

A sensation is then made up of quality, intensity, duration 
and extent; and no sensation can exist without at least the first 
three of these attributes. 


CLASSIFICATION OF SENSATIONS 1S 


Sensations are classified according to the sense-organ to which 
a stimulus must be applied in order to produce them (eye, ear, 
nose etc.); and, according to whether the sense-organ is on the 
surface of the body or not, they are divided into two classes, 
sensations of the special senses and organic sensations. The 
eyes, ears, nose, tongue and skin, being all more or less super- 
ficially situated, hearing, smell, taste, and the cutaneous sensa- 
tions are grouped together as the special senses (the “ extero- 
ceptive field’ of Sherrington): and, inasmuch as the muscles, 
tendons, joints, alimentary canal, lungs etc., are more 
deeply situated, sensations from these organs are grouped 
together as organic sensations (the “ proprioceptive field’”’ of 
Sherrington). 

This division into organic sensations and special sensations is 
obviously of an arbitrary character. All sense-organs are peri- 
pheral so far as the brain is concerned, and there is no essential 
difference between a muscle-spindle and a tactile corpuscle. If 
the reader is inclined to object that the stimulus in one case is 
from without and in the other from within, let him make firm 
external pressure on his own abdomen and he will find that the 
stimulus from without can give rise to “ organic ’’ sensation; or 
let him blow up his Eustachian tubes (Valsalva’s experiment), 
and he will find that stimulus from within can give rise to 
‘“ special ’’ sensation (hearing). It is true that the deep situation 
of the end-organs of so-called “ organic ’’ sensations prevents 
their being so accurately observed as the so-called “ special ”’ 
senses; but this does not constitute a real psychical difference 
in their nature. We must therefore reject the distinction 
between organic and special sensations as serving no purpose in 
the study of psychology, although there may be physiological 
differences. 

Our classification of sensations will therefore be as follows: 


Visual sensations (stimulus: hght)— 


Sensations of brightness. 
Sensations of colour. 
Auditory sensations (stimulus: air-vibration)—- 
Sensations of noise. 
Sensations of tone. 
Olfactory sensations (stimulus: ? chemical action of 
odorous particles). 
Gustatory sensations (stimulus: ? chemical action of 
certain substances). 


16 MIND AND ITS DISORDERS 


Cutaneous sensations— 


Sensations of pressure or touch (stimulus: mechanical). 

Sensations of pain (stimulus: mechanical, thermal, 
electrical or chemical). 

Sensations of warmth (stimulus: thermal). 

Sensations of cold (stimulus: thermal). 

Head and Rivers have demonstrated that the skin is supplied by two 
distinct systems of sensory nerves, the “ protopathic ’’ and the “ epicritic ”’. 
The former depends upon definite sensory end-organs and the areas be- 
tween these are supphed with epicritic sensibility. The protopathic end- 
organs have a high threshold—e.g., the ‘‘ heat spots’ do not respond to 
temperatures below 37° C. or the ‘‘ cold spots’’ to temperatures above 
26° C. in the absence of epicritic sensation. Accuracy of localization 
is dependent upon the more recently evolved epicritic system. It 


should be mentioned, however, that these observations have not 
passed unchallenged. 


Muscular sensations (stimulus: contraction of or pressure 
on muscle). 

Tendinous sensations (stimulus: stretching of tendon). 

Articular sensations (stimulus: pressure on articular 
surfaces). 

Circulatory sensations (stimulus: change in arterial or 
venous tension). 

Sensations from the alimentary canal— 


(a) Pharyngeal sensations (stimuli: mechanical, 
thermal or chemical; dryness of ‘mucous 
membrane). 

(>) Esophageal sensations (stimuli: mechanical, 
thermal or chemical; antiperistalsis). 

(c) Gastric sensations (stimuli: distension, presence 
of abnormal substances in the gastric con- 
tents, dryness of the mucous membrane; anti- 
peristalsis). 

(dz) Intestinal sensations (stimuli: distension, peri- 
stalsis). 


Respiratory sensations (stimuli: excessive or deficient 
supply of oxygen, irritating substances). 

Urinary bladder sensations (stimulus: distension). 

Sexual sensations (stimuli: change of blood-supply and 
secretory activity of genital apparatus, contraction of 
muscle etc.). 

Static sensations (stimulus: difference of pressure in 
semicircular canals). 


ATTRIBUTES OF SENSATION ay, 


These are the most important, but the student will be able to 
supplement the list from his experience of cases of heart disease, 
thrombosis, cholelithiasis etc. Moreover, it is believed by 
certain writers that some people are endowed with senses of 
which others have no experience. The Psychical Research 
Society claims to have accumulated a mass of evidence that 
telepathy and other phenomena, usually classed as “ occult ”’, 
undoubtedly occur; from which it should be concluded that 
people who have experienced any such manifestations must be 
endowed with a sense of which most of us are deficient. Would 
that we had some such sense to aid us in the solution of difficult 
psychological problems ! 

Since the intensity, duration and extent of a sensation are 
always the intensity, duration and extent of some quality of 
sensation, it follows that quality is the most important attribute 
which we have to consider. For convenience, however, it is 
more useful to consider the minor attributes of sensation first. 

The questions which arise in this connection are: What is the 
smallest intensity, duration and extent of a sensation that can 
be experienced in the various sense departments? By how 
much must a stimulus be increased in order to cause an increase 
of sensation ? And what is the greatest intensity, duration and 
extent of each that can be attained ? 

Intensity.— Just-noticeable sensations. If we go into a room 
from which all light is excluded, we experience a sensation of 
blackness; but, in addition to this, we have many faint sensations 
of light, due to stimulation of the retina by the ordinary processes 
of metabolism. Owing to this intrinsic retinal light, there is con- 
siderable difficulty in determining the least light-intensity which 
is just noticeably brighter than the black of the field of vision. It 
has, however, been estimated, by passing a current of electricity 
through a platinum wire until it became just visible, that the 
least noticeable intensity of light is approximately one three- 
hundredth of the light of the full moon reflected from white 
paper. It is curious that, so far as I am aware, this intensity 
has never been expressed in terms of candle-power, the usual 
standard of measurement of light. 

In audition, as indeed in all other sense departments, there 
is considerable difference between individuals. As an average 
result, however, it has been ascertained that a normal individual 
can just hear the sound ofa cork pellet, weighing one milliigramme, 
gt millimetres distant from the ear, falling through one milli- 


metre on a sheet of glass. This result is obtained under the 
a 


18 MIND AND ITS DISORDERS 


experimental condition of absolute silence, the reason for which 
we shall see presently. Under similar conditions we would 
find that an ordinary musket-shot could be heard at a distance 
of 7,000 metres (about 34 miles). 

The just-noticeable sensation for pressure differs in different 
parts of the body. One five-hundredth of a gramme can be 
sensed on the forehead, eyelids, temples, outer surface of the 
forearm and back of the hand; but it requires no less than one- 
twentieth of a gramme to be sensed on the cheeks, nose, palm 
of the hand, abdomen and thigh. On the nails and heels the 
just-noticeable weight is as much as one gramme. 

Up to the present, the other senses have not been to any 
extent subjected to investigation with a view to determining 
the just-noticeable sensation in each case. 

One sense may sometimes be ousted by another of great 
intensity. For example, it sometimes happens that one is 
unable to smell a flower or taste a delicacy on account of a noise 
occurring when one attempts to do so. The one sense appears 
to be capable of inhibiting the other. 

Extent.—The senses that play the most important part in the 
perception of space are those of touch and vision. Accordingly 
these senses alone receive consideration in determining the 
smallest amount of space which can be appreciated by them. 

If two white threads placed together against a dark back- 
ground at a convenient distance trom the eye, be gradually 
separated, it is found that they can be seen as two instead of 
one, when they subtend an angle of one degree at the cornea. 

The appreciation of two cutaneous stimuli as separate from 
one another varies enormously in different parts of the body, to 
such an extent that it is doubtful whether any two parts of the 
skin are the same in this respect. On the finger-tips, for instance, 
two compass-points can be distinguished as two separate impres- 
sions when they are one millimetre apart; but upon the skin of 
the back the distance has to be 60 millimetres. 

Duration.—In estimating the duration of a sensation we are 
met with the difficulty that it does not immediately cease with 
its stimulus. For this reason a rotating disc, half spectral red 
and half spectral green, appears white. In order that the colours 
may not fuse in the whole extent of the circumference of the 
disc, it is necessary that the disc should rotate less rapidly than 
four times per second: a light-stimulus of minimal duration gives 
a visual sensation lasting one-eighth of a second. 

In order to find the least noticeable duration of pressure, the 


WEBER'S LAW 19 


finger is lightly laid upon a toothed wheel, which is made to 
rotate. At a certain velocity the teeth of the wheel cannot be 
separately distinguished. From an experiment of this nature, 
the minimal duration of pressure-sensations can be determined. 

Although the minimal intensity, duration and extent of sensa- 
tions have been separately considered, it is to be observed that 
the minimum in each case is dependent upon the other attributes. 
For example, a point of light of given intensity may not be 
appreciable to the senses, whereas a square foot of light of the 
same intensity may be easily distinguished. Moreover, if this 
square foot of light lasts but a fraction of a second, it may be 
inappreciable to the senses; whereas, if it be allowed to last 
for half a minute, it may become perfectly obvious. 

The maximal intensity of sensations is, as a rule, so unpleasant 
or painful that the value of introspection is destroyed. The 
greatest appreciable intensity of sensations, therefore, cannot be 
determined. 

The maximal extent of visual and cutaneous stimuli is pro- 
duced by stimuli of the whole of both retinz and the whole of 
the skin respectively. 

The maximal duration of sensations has not been determined. 

Weber’s Law.—We now come to the last question: By how 
much must a stimulus be increased in order to produce a just- 
noticeable difference in sensation ? 

It has been shown that the answer to this question varies for 
the different sense modalities. A light stimulus must be in- 
creased by one-hundredth in order to produce a clear increase 
of sensation. Sound and pressure stimuli must be increased by 
one-third, and muscular (estimation of weights) by one-seven- 
teenth, for the production of a clear increase of sensation. 

To take an example: If a weight of one gramme be allowed to 
rest on the hand, it is necessary to add one-third of a gramme, 
and if a weight of a pound be allowed to rest on the hand, it is 
necessary to add one-third of a pound, and no less, in order that 
the observer shall notice an increase of weight in each case. 

This law was discovered by the physiologist Ernst Heinrich 
Weber, and has accordingly been called after him, ‘“‘ Weber’s 
law’’. It was, however, only in special cases that he examined 
its validity. The general applicability of the law was demon- 
strated by Gustav Theodor Fechner, who reduced it to the more 
general form: Sensation increases as the logarithm of the stimulus, 
the logarithmic base varying for the different sense modalities. 

The law is not absolutely correct, however, for sensations of 


20 MIND AND ITS DISORDERS 


very high and very low intensity: it applies only to those of 
moderate intensity. 

Weber’s law is constantly being exemplified in our everyday 
life. It explains why an artificial light is useless in a room 
already illuminated by the sun while it is of great utility in the 
dim twilight, why we can hear a pin drop in a silent room while 
we cannot hear ourselves speak in a boiler-shop and why we 
cannot feel a tumour in a patient’s abdomen when he contracts 
his abdominal wall. 

There are various interpretations of the law. According to 
the psychological view, each sensation consists of a large number 
of elementary units, and those who hold this view speak of 
‘quantities ’’ of feeling. Their interpretation of Weber’s law is 
that the quantities of our feelings are related logarithmically 
to the quantity of stimulation arousing those feelings. Psycho- 
physical interpretations are based on the fact that weak stimuli 
make nerve-tissue more excitable without overcoming the resist- 
ance at the synapses, a feature which is exemplified by Sherring- 
ton’s experiments illustrating “facilitation”. Elsas has pointed 
out that a chemical balance, in so far as its frictional resistance 
to indicate small changes of weight is concerned, obeys Weber's 
law. Ebbinghaus supposed the intensity of sensation to depend 
on the number of neural molecules which are disintegrated in 
a unit of time. 

It would seem that a psycho-physical interpretation of Weber’s 
law lies nearer the truth than the psychological which, after all, 
is but a restatement of the facts; but it is beyond the scope of 
this work to enter into a discussion of the relative merits of 
these various hypotheses. 

We now proceed to the consideration of sensation qualities. 


VISUAL SENSATION. 


The characteristic quality of visual sensations is colour. The 
number of different colours that can be normally distinguished 
has never been determined; it amounts to many thousands. 
The different shades of colour that can be distinguished in the 
solar spectrum alone number 160; but many new colours can 
be constructed by mixtures of these. Further, the solar spec- 
trum does not include white, black or grey, which are also colours 
from a psychological point of view: the physical fact that white ~ 
light may be resolved by means of a prism into all the colours of the 
rainbow has no bearing upon the psychological quality of white. 


VISUAL SENSATION 21 


If a spectral colour be illumined by white light and the intensity 
of that light be increased or diminished, the guality of the colour- 
sensation changes; a spectral red, for example, becomes a pink 
or a brown when the intensity of the illumination is respectively 
increased or diminished. It has been shown that each of the 
spectral colours gives about 600 sensation qualities during the 
gradual intensifying of its illumination with white light. Similar 
observations might be made on the number of sensation qualities 
resulting from an intensively graduated illumination of a spectral 
red by a blue light, and so forth. 

The sensitive layer of the retina consists of rods and cones. 
At the fovea centralis, the spot of clearest vision, only cones are 
present. In the region surrounding this, rods and cones are 
present in fairly equal numbers; while the periphery is almost 
devoid of cones. The cones are stimulated by bright light only, 
and it is through their reaction to hght that we are capable of 
appreciating colour. The rods are much more sensitive and are 
rapidly exhausted by bright hight. It is by their reaction that 
we are enabled to see in a light too feeble to stimulate the cones, 
but they do not react to colour; coloured objects in a dim light 
look black, white or grey, red objects appearing black because 
red does not stimulate the rods. The difference between the 
excitabilities of the rods and cones may be studied on a starlit 
night when one finds that many of the dimmer stars, which are 
easily seen at the periphery of the retina, disappear if one looks 
straight at them, so that the image falls on the rodless fovea. 

There are about half a dozen theories of colour-sensation 
extant, none of which appears to the present writer to be quite 
satisfactory. A satisfactory colour theory must be able to 
account for all the facts of colour-blindness. It must account 
for cases of “ total’’ colour-blindness in which all visual images 
appear as shaded drawings, for cases of “ red-blindness’’ and 
“ green-blindness ’’ as well as for the more frequent cases of 
“red-green blindness ”’ and for cases of monocular colour-blind- 
ness; it must also account for the fact that we never come across 
cases of black-white-grey blindness with retention of vision for 
spectral colours. 

Edridge Green believes that the function of the rods is to 
manufacture visual purple, which accumulates round the cones. 
Light has the property of decomposing the visual purple and 
at the same time of generating an electric stimulus to the cones, 
which varies in character with the wave-length of the ray of 
light. Discernment of the colour from the character of the 


22 MIND AND ITS DISORDERS 


stimulus is the function of the occipital cortex. Edridge Green 
distinguishes two classes of colour-blind persons, viz., those 
who are unable to see the colour of one or other end of the spec- 
trum, and those who cannot recognize the difference between 
certain colours. The latter can only see five, four, three or fewer 
of the primary colours. | 

Wundt supposed every retinal excitation to be compounded 
of two separable constituents, a colour excitation and a bright- 
ness excitation. When the achromatic excitation occurs, we 
sense black, white or grey. A chromatic excitation implies the 
presence of the achromatic. When a chromatic excitation 
occurs, any difference in the sense-quality results from a varia- 
tion in the wave-lengths of light. 

The theory of Hering takes cognizance of the fact that there 
are only six colours which cannot by introspection be analyzed 
into simpler colours. These are black, white, red, green, blue 
and yellow. Violet is clearly analyzable into red and blue, 
orange into red and yellow, and brown into red and black. The 
theory assumes that there are three kinds of visual substance 
in the retina, probably lipochromes, whose katabolism gives 
white, red and yellow, while their anabolism gives black, green 
and blue respectively. 

The retina is not uniformly sensitive to colour over its whole 
surface. It may be demonstrated by means of the perimeter 
that there are three colour-zones merging into one another: 
an inner where all colour-tones are accurately estimated, this 
gradually passing into an intermediate zone where all colours 
are apprehended as blue, yellow, black, white or grey; and an 
outer zone in which all colours are apprehended as black, white 
or grey. These phenomena, when considered in conjunction 
with the fact that red-green is the most common variety of 
colour-blindness and blue-yellow a much rarer variety, suggest 
that black-white-grey vision is the first in order of evolution, 
blue-yellow next and red-green the last to develop. They also 
suggest that the cones are more recent in their evolution than 
the rods. 

Near the centre of each retina there is a spot, at the entrance 
of the optic nerve, which is totally blind. This is easily demon- 
strated. If the accompanying diagram be held at a distance 
of about 12 inches in front of the left eye, the right eye being 
closed, and if the reader gaze at the cross, the spot will dis- 
appear. It is, however, to be observed that the spot is replaced 
by the white of the paper, not by a blank. And if the reader 


AFTER-IMAGES 23 


take the trouble to copy the diagram upon the middle of his 
morning newspaper and carry out the observation again, it will 
be seen that the blind-spot is filled in with print. If a vertical 
or horizontal line be drawn, that line does not appear shorter 
when the middle of its image falls upon the blind-spot. Such 
observations demonstrate that, owing to perceptual experience, 
the blind-spot has the same spatial value as the rest of the 


Fic. 4. 


retina and tliat any area whose image falls upon it is filled up 
in the same way as the rest of the surface under observation. 

Complementary colours are those whose combination gives 
white as a result, or at least a grey with no admixture of spectral 
colour. Such complementary colours are carmine and _ bluish- 
green, red and verdigris, orange and greenish-blue, yellow and 
blue, yellowish-green and violet, green and purple; in a sense, 
black and white may also be regarded as complementary colours. 

If any of these colours be presented in the field of vision, the 
rest of the field is tinged with the complementary colour. This is 
best demonstrated by the following experiment. On a piece of 
black cloth lay a square of grey paper with a hole in the centre. 
Under the grey paper pass towards the hole a slip of white or 
coloured paper. As soon as the coloured slip makes its appear- 
ance in the hole the grey square is immediately tinged with the 
complementary colour. If the slip be white, the grey paper 
darkens; if carmine, it is tinged with bluish-green; if blue, with 
yellow, and so on. This is the phenomenon of simultaneous 
contrast. 

The best examples of successive contrast are negative after- 
images. If we look at the sun for a moment and then look at 
a grey background, we see on the background a dark grey or 
bluish-grey disc, the negative image of the sun. This is an 
extreme case; but after-images are easily obtained by gazing 
for an extended time, say one minute, at a strip of coloured 
paper.. It is found that the after-image is of the complementary 
colour to that given in the stimulus. 

It is also to be observed that the phenomena of contrast are 
effective in the after-image. This is, perhaps, best exemplified 
by Hering’s original experiment, which is as follows:—Lay 
two small strips of equally dark grey paper on a background 


24 MIND AND ITS DISORDERS 


of which one half is white and the other half black, in such a 
way that they lie on opposite sides of the border-line and parallel 
toit. Gaze for one minute at a point on the border-line. Close 
or cover the eyes, and the negative after-image appears. The 
difference of the brightness of the strips in the after-image 1s 
generally much greater than during direct vision. A phase 
occurs in which the difference in brightness of the two halves of 
the background disappears, and both after-images of the strips 
are still clear, one brighter and one darker than the background. 

This experiment shows that the difference in the brightness of © 
the after-image depends upon a different state of excitation of 
the corresponding parts of the retina; and from this we must 
conclude that the two parts of the retina corresponding to the 
two strips of equally dark grey paper were differently stimulated 
during the original observation. The conclusion is, therefore, 
that ‘‘ contrast is occasioned, not by a false idea resulting from 
unconscious conclusions, but by the fact that the excitation of 
any portion of the retina, and the consequent sensation, depends 
not only on its own illumination, but on that of the rest of the 
retina as well’’.* 

We have observed that in negative after-images the colours 
are complementary to those given in the original stimuli. In 
positive after-images the colours are an exact reproduction of 
those given in the original stimuli. They are not as easily 
induced as negative after-images; but, when they occur, they 
precede the formation of the negative after-image. 


AUDITORY SENSATION. 


The characteristic quality of auditory sensations is “ pitch ”’. 
The notes of a piano give tones of different “ pitch ’’, their differ- 
ence depending upon the rate of vibration of the wires and the 
resulting rate of vibration of particles of air. 

The normal ear can distinguish many more tones than are 
represented on an ordinary piano; not only of a higher and 
lower pitch, but also many intermediate tones which cannot be 
produced on a piano without special adaptation of the instru- 
ment. By means of various scientific appliances it has been 
demonstrated that we can normally distinguish about 11,050 
different tones. This number corresponds to the number of 
hair-cells in the cochlea, yet physiologists are not inclined to 
the view that each hair-cell is tuned to a particular tone. 


* James, “ Principles of Psychology,” vol. ii., p. 19. 


CUTANEOUS SENSATIONS 25 


Besides musical tones, the ear is capable of distinguishing 
many varieties of noise. Noises are of two kinds, the first being 
due to air-vibrations of insufficient duration to give rise to a 
musical tone (two or three vibrations of extreme rapidity), and 
the second to a confused mixture of musical tones among them- 
selves or with noises of the first class. To the first class belong 
eer bitice we banes.s. cracks “ etc;; andito the second class: the 
rumble of the street and the roar of the waterfall. 

The appreciation of pitch is not exactly the same for the two 
ears. A given tone in the middle of the musical scale is com- 
monly apprehended by the right ear as being of a slightly higher 
pitch than by the left ear, the difference corresponding to that 
of two or three vibrations per second for the middle notes of 
a plano. 

The same tone gives a different sensation quality when sounded 
upon different musical instruments. This depends partly upon 
the mechanism of the particular instrument; cf. the percussion 
of a piano, the scraping of a violin and the reedy vibration of 
an oboe. The different timbre or clang-tint of these instruments 
depends also on the formation of overtones. Overtones are 
tones of less intensity and higher pitch than the fundamental 
tone, which depend for their formation upon partial vibrations 
of the column of air in a wind-instrument or of the string in 
string-instruments. 

It has been suggested that the appreciation of pitch obeys 
Weber’s law, the pitch increasing in direct proportion to the 
logarithm of the vibration-rate. 


CUTANEOUS SENSATIONS. 


The cutaneous sensations are four in number—pressure or 
touch, pain, warmth and cold. 

These are four distinct sense-modalities, as different as those 
of vision and hearing, each having a series of end-organs sub- 
serving its own particular function. According to von Frey, 
sensations of pressure are derived from the hair-bulbs and 
Meissner’s corpuscles, those of pain from the free nerve-endings 
in the epidermis, those of warmth from Ruffini’s cylinders and 
those of cold from Krause’s end-bulbs. 

With the head ofa pin it may be ascertained that the sensation 
of pressure is more intensive at some spots of skin than at others, 
and with the point that the sensation of pain is more intensive 
at some spots than at others. Similarly, with a suitable blunt 


26 MIND AND ITS DISORDERS 


instrument so adapted that its point can be kept warm or cold, © 
it may be ascertained that there are maximum spots for warmth 
and maximum spots for cold. These spots are respectively 
known as the pressure-spots, pain-spots, warm-spots and cold- 
spots. Of these, the pain-spots are by far the most numerous, 
and the cold-spots are more numerous than the warm-spots. 

It has been found that these spots are not always in identically 
the same place, but that each moves about over a small area of 
skin. It would be more strictly. true to say that there are 
“blotches ’’ of skin for these various sensations, and that these 
“blotches ”’ slightly overlap one another. 

The pressure-spots are situated over the hair-bulbs and are 
consequently to be found on the “‘ windward ”’ side of the hairs. 
Weak sensations of pressure can be evoked by moving the tips 
of the hairs. Pressure-spots are not, however, limited to hairy 
parts of the skin: they are quite as numerous on the palm of 
the hand and the sole of the foot. We soon become adapted 
to sensations of pressure, e.g., pressure of clothing, because 
the pressure-sense is easily fatigued. 

Similarly the sense of temperature is easily fatigued. This 
may be demonstrated by Locke’s experiment :—Fill three basins, 
one with warm water, one with cold and the third with water 
of moderate warmth. Place one hand in the first basin and one 
in the second. After a minute, place both hands in the third 
basin. The water will feel warm to the hand which has been 
in the cold water, and cold to the hand which has been in the 
warm water. But for the rapid exhaustion of the cold-sense, 
our morning tub would be almost intolerable. 


TASTE: 


There are four taste-qualities:—sweet, salt, sour and bitter. 
If the nostrils be plugged with cotton-wool, the tongue pro- 
truded and a number of substances thus tasted, it will be found 
impossible to discover more than these four qualities of gustatory 
sensation, either alone or in combination. Suitable substances 
for this experiment are beef-tea, cod-liver oil, olive oil, alcohol 
and oil of cloves. With some of these there may be an addi- 
tional sensation of stinging or tingling of the tongue; but these 
will, of course, not be confused with gustatory sensations. 

It has been discovered that certain of the lingual papille are 
sensitive to only one of the four taste-qualities, those exclusively 
sensitive to bitter being situated at the posterior part of the 
tongue. 


SMELL 27 


Sensitiveness to one taste-quality may be fatigued while the 
other taste-qualities remain unaffected. This would appear to 
indicate that each gustatory cell subserves a specific taste- 
quality. 

A certain amount of contrast effect can be demonstrated 
to exist in the case of gustatory sensations. For example, a 
salt solution so weak that it cannot be tasted under ordinary 
circumstances can be distinctly recognized as salt, if the mouth 
be first washed out with a strong solution of sugar. In this way 
it has been shown that a contrast exists between salt and sour, 

and between sweet and sour. Bitter gives no contrast effects. 


SMELL. 


The psychology of smell is yet in its infancy, because the 
Schneiderian membrane does not lend itself to direct stimulation 
like the end-organs of other senses. 

That smell plays an important part in the ordinary discrimina- 
tion of flavour is shown by the fact that we cannot appreciate 
flavour when the nasal passages are occluded. 

The sense of smell is easily fatigued; and this phenomenon has 
proved invaluable in elucidating its psychology. For example, 
it has been found that, if the olfactory sense be exhausted for 
iodine, the odours of oil of orange, heliotropine and alcohol can- 
not be sensed at all, and that the sense is also partially exhausted 
for a large number of other substances. Again, by this method 
of exhaustion it may be shown that a large number of odours, 
which give an unitary sensation of smell, are really composed 
of a number of simpler olfactory sensations. Faded violets, if 
persistently smelt, soon give but a disagreeable odour of faded 
flowers. The initial odour of nitrobenzol is that of heliotrope; 
this almost immediately gives place to that of bitter almonds; 
this in turn gives place to benzene; then follows complete ex- 
haustion for all three odours. From observations of this nature 
it has been concluded that the innumerable olfactory qualities, 
which are experienced as simple and unitary, are in reality 
compounded of a comparatively small number of elementary 
olfactory qualities, probably about eleven. 

The practical experience of everyday life affords instances of 
the compensation or neutralization of one smell by another. . 
The odour of sanitas is antagonistic to that of feces, the scent of 
areca-nut to that of carious teeth, and the odour of carbolic acid 
to that of pulmonary gangrene. On the other hand, there is 


28 MIND AND ITS DISORDERS 


evidence of olfactory contrast between indiarubber and balsam 
of tolu or cedar-wood, and between feces and musk. Epicures 
also recognize a contrast between the odours of ham and cham- 
pagne, cheese and claret, game and Burgundy. 


THE SENSE OF POSITION AND MOVEMENT. 


The sense of position and movement is made up of a large 
number of sensations; mainly muscular, tendinous and articular. 

Sandow’s exerciser is a useful piece of apparatus for demon- 
strating the difference between these three kinds of sensation. 
The dumb-bells should be connected together by a couple of 
elastic bands. Place the foot upon one dumb-bell and stand 
upright with the other dumb-bell held in the hand, the elastic 
bands being put on the stretch. The sensation of tendinous 
strain will be noticed. Now stoop so as to relax the tension of 
the elastic bands. At the moment of complete relaxation there 
will be noticed a distinct jog due to the approximation of articular 
surfaces. Now stand upright once more and flex the arm to a 
right angle. The characteristic sensation of muscular contrac- 
tion will be noticed in the region of the biceps. 

If the front of the forearm be rendered anesthetic by means 
of an ether spray, it can be demonstrated that there is no differ- 
ence between the sensations of voluntary muscular contraction, 
e.g., of the flexor indicis, muscular contraction due to electrical 
stimulation, and deep pressure upon the muscle. From this it 
is to be inferred that muscular sensations are due to squeezing 
of the muscle-spindles (the sensory end-organs of muscle) during 
muscular contraction, and not to any cutaneous sensation from 
movement of the skin by swelling of the muscle belly. 

It is a matter of controversy how great a part is played in 
the perception of movement and position by each of the above 
sensation qualities. At present the claims of articular sensation 
are rather in the ascendant, since Goldscheider has demonstrated 
that, when a joint is rendered artificially anaesthetic, movement 
becomes much less perceptible, whether it be active or passive. 
But we shall have occasion to deal with this subject more fully 
in the next chapter. 


UNCONSCIOUS SENSATIONS. 


The conclusions at which we have arrived in the present 
chapter have been the result of introspection, special attention 
having been directed to these sensations as they occurred; but 


UNCONSCIOUS SENSATIONS 29 


we have also to remember that the sensorium is constantly 
receiving impressions, as it were automatically, independently 
of consciousness and without our knowledge. As I write these 
sentences, I experience no sensation of the pressure of my clothes, 
of the chair I sit on or of the pen I hold; I do not notice the cool 
air blowing across my cheek, the tick of the clock, the conversa- 
tion beneath my window, the noise of passing vehicles, the 
swaying of the lamp, the puffs of smoke from my pipe or even the 
flavour of the burning tobacco. All these sensations are outside 
my phenomenal consciousness, and it might be quite impossible 
voluntarily to recall them; they are unconscious sensations. 
For the present suffice it to remark that they might possibly be 
recalled under hypnotism or by some other artificial aid; but 
we shall have occasion to refer to them in another chapter. 


CHAPTER IIT. 
PERCEPTION AND IDEATION. 


In the previous chapter we discussed the elementary sensations 
without which mentation would be non-existent, disregarding the 
external objects which, under normal circumstances, give rise 
to those sensations. We now advance one step nearer to the 
everyday working of mind and consider it in relation to things- 
in-themselves. In the present chapter it will be shown that 
the perception, apprehension and subsequent ideation of things- 
in-themselves are merely the result of experience. 

When I have an object before me, ¢.g., an orange, see it, 
perhaps feel it and know that it is an orange, I have a percept 
of it; when I think of an orange, I have an zdea of it. We shall 
see later that there is practically no psychological difference 
between these two processes, their chief difference being physio- 
logical. 

When I hold an orange before me, I experience sensations of 
pressure, coolness and yellowness. If I drop it on the table, 
there is a sensation of sound (a thud). If I eat it, there are 
sensations of sweetness, sourness and the characteristic flavour 
apprehended by the sense of smell. 

When I think of some particular orange which I have seen, I 
think of it in terms of these or some of these various sensations 
of pressure, coldness, yellowness, flavour etc.; and, as a matter 
of fact, I experience these sensations in a slight degree. There 
is a faint visual, olfactory and tactile image of the orange, a 
revived percept. I may further experience faint visual and 
auditory images of the word “‘orange’’, as well as a muscular 
sensation about the tongue similar to that felt when I say the 
word “‘ orange’, the so-called “ kinesthetic equivalent ’’. 

Three points are to be noted at this stage. In the first place, 
these various sensations are not apprehended as separate: they 
combine in the unitary percept or idea “‘ orange ’’; and it is only 
by our psychological analysis, by introspection, that we discover 

30 


THE PHYSICAL BASIS OF PERCEPTION 5 


that the percept or idea consists of sensations of various sense- 
modalities. 

Secondly, it is to be noted that not all combinations of sensa- 
tion will form a percept or idea. For example, the sense-qualities 
cold, red, sweet, high-pitched and painful refuse to combine to 
form an idea from lack of such an experience. 

Lastly, perception and ideation localize an object and give 
it a definite shape, occupying a certain amount of space. It 
follows that our percepts and ideas are in reality but abstractions, 
just as much as sensations are. We cannot perceive or ideate an 
object without giving it shape and placing it somewhere in space 
with an environment of its own; and this environment is an 
essential part of the perception. When we have a percept of an_ 
object, we are in reality making an abstraction from our percep- 
tion of space in general. 

The Physical Basis of Perception.—From the study of word- 
_ perception we learn that the physical basis of visual percep- 
tion is the anterior part of the occipital cortex,* and that of 
auditory perception the second temporo-sphenoidal convolu- 
tion; but, whereas the function of word-perception is limited to 
the left hemisphere (in right-handed people), both hemispheres 
participate in the perception and ideation of objects other than 
words (see p. 110). From clinical and experimental observations 
the physical bases of gustatory and olfactory perceptions have 
been localized in the limbic lobes, and tactile in the post-central 
convolutions (parietal association-area) of the two sides. Broadly 
stated, the faculty of perception is localized in the association 
areas of the two cerebral hemispheres. 

The physiological difference between perception and ideation 
is that percepts are aroused by stimulation of the corresponding 
sensory end-organ, while zdeas are aroused by way of association- 
fibres. Take, for example, the domain of vision. When I 
perceive a brick, my occipital cortex is stimulated by way of the 
retina; when I think of the brick, they are stimulated by way 
of association-fibres, from the left temporal convolutions if I 
hear a conversation about bricks, from the left angular gyrus 
itself if I have seen the word “ brick ’’. 

The actual mechanism of the process must be conceived as 
the overcoming of resistance at certain synapses in the per- 


* The angular gyrus was formerly considered the physical basis of visual 
perception, but it has been shown that destruction of this convolution does 
not cause ‘“‘ mind-blindness’”’ unless the underlying longitudinal fasciculi | 
are also damaged (vide A. W. Campbell’s “‘ Localization of Cerebral 
Function ’’). 


32 MIND AND ITS DISORDERS 


ceptual area concerned, the particular synapses varying from 
percept to percept or from idea to idea, probably with protrusion 
of certain gemmules and retraction of others. 


SPACE-PERCEPTION. 


Some psychologists believe the spatial idea to be innate. This 
appears to be an unnecessary hypothesis. The new-born child 


@) 
CHES 
SHOULDER 


& TASTE 


Fic. 5. 


has but to experience movement of its own limbs, and of objects 
in its environment, for the foundation of the extensive idea to 
be already laid. 


BINOCULAR VISION 33 


The foundation being laid, development of the spatial idea 
depends mainly upon our experience in the domains of vision, 
touch, muscular sense and the static sense. It therefore becomes 
our duty to ascertain in what manner these various senses 
contribute to our idea of spatial extent. 


Visual Space-Perception. 


We have already stated that the retina varies all over its 
surface in the mode of which it reacts to colour. This character- 
istic gives each small portion of the retina its “local sign’”’, as it 
has been called; and it is by means of these local signs that we 
are enabled to recognize in which part of the visual field a given 
object is situated. It has been suggested that the situation of 
the object is not ascertained by movement of the eye, because 
it is possible in a dark room to localize with exactitude an electric 
spark of such brief duration as to give no time for eye-movement. 
On the other hand, it has been observed, especially in young 
babies, that stimulation of any portion of the retina by a light 
produces a reflex movement of the eye, such as to bring the 
image of the light to the yellow spot; and in the above experi- 
ment a reflex eye-movement may occur after the disappearance 
of the electric spark, this eye-movement contributing to the 
knowledge of the situation of the spark. ) 

Although visual sensations aroused by objects in the external 
world are produced by stimulation of the retina, we do not 
localize an object giving rise to a visual image in the neighbour- 
hood of the eye; we refer it to some situation in our environ- 
ment. This feature has been magnified by some psychologists 
into a special faculty of mind, “ eccentric projection ’’, whereby 
our mental states are, as it were, thrown outwards into the 
world of experience. Others again minimize the fact, asserting 
that visual sensations are not associated with eye-sensations. 
To the present writer introspection shows that visual sensa- 
tions are associated with muscular sensations about the eye 
and that these contribute considerably to the spatial idea. But 
in whatever way we regard this mental state, there is no doubt 
that we have a something-there feeling superadded to the crude 
sensations and that we place in these ideational content, derived 
from previous experience of similar sensations. 

The two eyes regard the world from different points of view. 
Consequently there is a difference between the images produced 
upon their respective retine. This will be rendered evident if 
the reader look over the edge of this book at the pattern of 

4 


34 MIND AND ITS DISORDERS 


the carpet beyond and close alternately his right and left eyes. 
The study of this fact, especially by the aid of the stereoscope, 
throws much light on the psychology of perception. 

Now although there is a different picture for each eye, we do not 
experience two percepts, but one. There is a tendency to com- 
bine any number of sensations given in consciousness into one 
idea, and this tendency, which is known as the “ unity of idea- 
tion ’’, may be shown by means of the stereoscope to be very 
strong. For example, if there are placed in the stereoscope two 
circles of slightly different diameter, one for each eye, we see one 
circle of medium size. If instead of the circles there are two 
horizontal lines, one for each eye, and one slightly above the 
level of the other, the two lines fuse into one, midway between 
the levels of the original two. 

But, as we have already seen, not all combinations of sensa- 
tions will fuse to form a single idea. If, for example, a slide 


ihe Sita eae 
Hic; 0: 


similar to Fig. 6 be placed in the stereoscope, we do not see a 
solid cross, but we see one of the lines crossing the other and 
obliterating it at the point of intersection. 

Fig. 7 gives a most puzzling result. Far from giving an 
unitary percept, the different parts of the letters keep chasing 


M W 


FIG. 7. 


each other out of the field. These are examples of “ideational 
rivalry ”’. 

We now proceed to the stereoscopic figures, which show how 
binocular vision gives the idea of depth. 


eo @ e @ 
OT 
© e @ 


Fic. 8. 


In Fig. 8 we see two dots, the right being more distant than 
the left. 


STEREOSCOPIC EXPERIMENTS B5 


Fig. 9 is seen as a single line, with the upper end nearer to the 
observer than the lower. 


Fic. 9. 


Fig. Io is seen as two circles, one in the middle of the other, 
but nearer to the observer. In other words, it appears as a 
truncated cone viewed from above. 


O © 


Hite roe 


Fig. 10A appears as a hollow truncated cone viewed from 
below. 


Q) © 


FIG. {IOA, 


36 MIND AND ITS DISORDERS 


Fig. II appears as one line curved toward the observer as in 
looking down on an old-fashioned croquet-hoop. 

In considering these various results it will be seen that there 
is a tendency on the part of the organism to attach ideational 


OT Geen Te 


content to these groupings of sensation. If we place two marbles 
horizontally in front of the eyes in such a way that the right 
marble is farther off than the left, we have the conditions of 
Fig. 8, the marbles appearing when viewed with the left eye to 


BiG et?2, 


be closer together than when viewed with the right; and we 
have the conditions of Fig. 9 if the upper end of a stick be tilted 
towards the observer. To the left eye it will appear to lean 
to the right, and to the right eye to lean to the left. 


SIMPLE PERCEPTUAL EXPERIENCES ay! 


On the other hand, conditions never occur in the world of 
perceptual experience in which an object appears to one eye to 
be horizontal and to the other vertical: hence, we are unable to 
combine the images of Fig. 6 or Fig. 7 into a single percept. 

The tendency to attach ideational content to images is further 
illustrated by some of the geometrical illusions. The angles of 
perceptual experience are for the most part right angles; there 
is consequently a tendency to assimilate all angles to a right 
angle and hence to overestimate acute angles and to under- 
estimate obtuse angles. When looked at with one eye, so as to 
eliminate the true perception of depth gained by binocular vision, 
Fig. 12 appears as a vertical line in the plane of the paper crossed 
at right angles by a line passing through the plane of the paper, 
especially if an extremity of the latter line be fixated. 

The illusions in the following figures are adduced to illustrate 
the part played by muscular sensation in the estimation of space. 


Fic. 13. 


Although a and 0b are the same length, } looks longer than a ; 
the interpretation being that there is more muscular effort 
required to carry the eye along 0, with all its interruptions, than 
along the uninterrupted a. The same explanation applies to 
the illusions in Fig. 14. 


FIG. 14. 


In Fig. 15 the horizontal and vertical lines are of equal length, 
but the vertical line appears the longer because there is more 


Fic. 15. 


musculature brought into play in moving the eyes up and down 
than in moving them laterally. Similarly, although the lines 


38 MIND AND ITS DISORDERS 


are exactly bisected, the upper half of the vertical line appears 
longer than the lower half, because the muscles which move 
the eye upwards.are not as well developed as those which move 
it downward. Looked at with one eye, the outer half of the 
horizontal line appears longer than the inner half, because the 
external rectus is not so well developed as the internal rectus, 
and therefore more effort is required to move the eye outward 
than to move it inward. 

The general conclusion from all these otperinen is that we 
tend to attach to any group of sensations the content of some 
idea, which has resulted from our experience of “‘ things ”’ as they 
are usually presented to us. 

There is yet one more illusion of the greatest interest which 
demands our attention, as illustrating this point and also the effect 


+ ++ 
+ ++ 


After-images of a right-angled cross. Perspective of a right-angled cross. 


Fic. 16. PiGe 7. 


of muscular movement in determining the nature of our per- 
ceptions. Let the reader obtain an after-image of a right-angled 
cross placed horizontally in front of the eyes. He will find that 
the shape of the after-image is changed as shown in the accom- 
panying diagram (Fig. 16), when he turns his eyes upward or 
downward to the right or left. The explanation of this illusion 
depends upon the perspective of a right-angled cross. If a real 
cross be situated in the four corners of the visual field, it gives the 
appearance represented in Fig. 17. 

Now “the brain” has nothing to do with after-images; it 
simply endows the sensations which it experiences with idea- 
tional content; and “ the brain’s”’ experience is that a line, in 
any of the four corners of the field of vision, which projects a 


ESTIMATION OF DISTANCE 39 


horizontal image on the retina, is not horizontal but tilted away 
from the centre, as in Fig. 17. Hence results the torsion of the 
horizontal line in the after-image of the right-angled cross. The 
reader may convince himself of this torsion by facing one of the 
walls of his room and looking upward to the right and left at 
the line formed by the junction of wall and ceiling, and of wall 
and floor. 

This furnishes additional evidence of the tendency to attach 
ideational content to sensations. It is also an illustration of the 
fact that ideas may be altered by the addition of movement- 
sensation to the content of consciousness. 

We have seen that binocular vision plays a large part in the 
estimation of distance. Muscular sensations caused by the effort 
of convergence also contribute very materially to the spatial 
idea. We are helped, too, by noting the amount of effort at 
accommodation, the amount of eye-movement required to pass 
several objects in review, the relative size of objects and the 
relations of their bases. Other indications of distance are 
uniformity and paleness of colouring, and the indistinctness of 
boundary lines, 


Cutaneous Space-Perception. 


It has been mentioned that the skin, on examination, presents 
areas of sensitivity to pressure, pain, warmth and cold. Now if 
we were to draw up a map of the whole of the cutaneous sur- 
face, a map based upon the distribution of these various sensi- 
tive areas, we would find that no two parts of the map exactly 
resemble one another. In other words, every portion of skin 
has its local characteristics; and it is by means of these local 
characteristics that we are enabled to determine the portion of 
skin stimulated at any time. We localize cutaneous sensations 
by means of their “local sign’’, in the same way as we localize 
retinal sensations by means of their “ local sign”’. 

We are not always quite accurate, however, in the localization 
of a cutaneous sensation. For example, stimuli are not well 
localized in the long axis of a limb, and in transverse localization 
there is less accuracy on the outer than on the inner side. There 
is also a large amount of error in parts of the skin which one 
does not see, e.g., the middle of the back. 

All parts of the skin are not equally capable of fecling as 
double the stimulus given by a pair of compass-points. In some 
parts the two points may give rise to one sensation, in other 
parts to two. For example, at the tips of the fingers the two 


40 MIND AND ITS DISORDERS 


points can be distinguished when they are but two millimetres 
apart, but in the middle of the back they are apprehended as 
one stimulus if they are less than 60 millimetres apart. 


Articular Space-Perception. 


It has been shown by Goldscheider that our perception of 
the position, attitude and movement of our limbs is dependent 
on sensations arising in the articular surfaces of their joints; 
since articular anesthesia, artificially induced by faradism or 
other means, almost completely abolishes such perception. The 
muscular sense, which hitherto has been credited with this 
function, has very little to do with it; the function of the mus- 
cular sense appears to be almost solely the appreciation of weight. 

The greater the velocity of movement of a limb, the smaller 
is the movement which can be perceived. The following table, 
quoted from E. W. Scripture, gives the just-perceptible move- 
ment around the various joints for the greatest velocity obtain- 
able without jarring. The figures indicate degrees: 


Second interphalangeal .. os! .. 1:03 10°20 
First interphalangeal me ey «O92 ee 
Metacarpo-phalangeal te ws <i 0-347 ,, Ones 
Wrist re ae bia a -«) 0°20 Goes 
Elbow ae oe phe “iP 7s) O40 eae 
Shoulder ie ex a ie oe) O92 57a 
im bye sr ra fs oe de .« 0°50 70-90 
Ankle e ae “ <% oe =k" E5 po kee 


Static Space-Perception. 


All the above forms of space-perception contribute to the 
knowledge of the position of parts of the body; but we are 
provided with yet another sense, by which we are enabled 
motorially to orientate the whole body. The labyrinth, con- 
sisting of the otolith organ and the semicircular canals, is an 
arrangement by which we become aware of change of position or 
change of movement of the head, and therefore of the whole 
body. It is owing to changes of pressure of the labyrinthine 
fluid and the otoliths against the walls of the labyrinth that we 
feel the rolling of a ship or the starting of a lift. 

It has been found that, when a person is placed in a closed 
chamber capable of being rotated on a vertical axis, he ex- 
periences a sensation of being rotated only at the beginning of 
rotation or during alteration of the velocity of rotation. As __ 
long as the velocity remains constant the chamber appears to 


SPACE-PERCEPTION AI 


him to be still; but when the rotation ceases or the speed is 
decreased, he feels as if he were being rotated even more strongly 
in the opposite direction. He can then demonstrate to himself in 
the following way that the sense-organ by which he experiences 
this sensation is within the head. If he bend his head forward, 
the axis of rotation appears to bend forward too; and if he bend 
the head sideways at a right angle, as if to rest it on one shoulder, 
he feels as if he were rotating on a horizontal axis parallel to the 
line of the shoulders. A patient with both labyrinths destroyed 
has no perception of space in the dark; so much so that, if he 
lie on the floor, he is unable to rise. 

It has further been shown that the labyrinth is the receptive 
organ for the reflex tonic contraction of the muscles of the body, 
whereby it is maintained in any given attitude. As you sit 
reading these pages, without any effort on your part the reflex 
tone of your muscles maintains your body in an attitude entirely 
different from that of a corpse placed in the same position, 
whose toneless muscles would allow the various parts of the body 
to succumb to the influence of gravity. Ewald has shown that 
each labyrinth maintains the tone of the muscles of the same 
side of the body, especially those of the neck and trunk, and the 
extensors and abductors of the limbs. As Sherrington remarks 
in his book “On the Integrative Action of the Nervous System”, 
the effect of the “ knock-out ’’ blow on the point of the chin in 
reducing a vigorous athlete to a toneless mass of flesh, whose 
weight alone determines its attitude, is due to concussion of 
the labyrinths. But this is a digression. So far as space-per- 
ception is concerned, the labyrinth serves to indicate to us 
changes in position of the body as a whole. 


Auditory Space-Perception. 


The localization of sound is much less accurate than that of 
cutaneous and retinal stimuli. It is assisted by movements of 
the head; but, even if the head be held perfectly still, we are 
able to estimate the direction of a sound with a fair degree of 
accuracy. 

Under experimental conditions, it has been shown that sounds 
are best localized when they are on the same level as the ears. 
There is no confusion, as a rule, between right and left; but 
mistakes occur in estimating whether a sound is in front or 
behind. Localization is rather more accurate in front than 
behind. It appears probable that sound is localized by means 
of pressure stimuli communicated to the hairs of the pinna, 


42 MIND AND ITS DISORDERS 


since localization is very inaccurate if the pinne be strapped 
back to the side of the head or an obstacle to sound be tied to 
each side of the head in front of the pinna. 


TIME-PERCEPTION. 


The study of auditory perception throws light not so much 
on our ideas of space as on those of time. 

When listening to music, we find that it is arranged according 
to a certain time or rhythm. Similarly when we listen to a 
series of monotonous sounds, they appear to arrange themselves 
in a certain rhythm. If, for example, we listen to the clicks of 
a metronome, they seem to fall into pairs or threes, or into pairs 
of twos or threes; or they may be arranged thus: 


or even thus: 


Fic. 19. 


If we listen to a metronome in some such way as this and, 
without counting, endeavour to discover how large a group can 
be apprehended as a single idea, we find that under certain cir- 
cumstances an unitary idea can be formed consisting of as many 
as forty-eight clicks, provided they succeed each other with 
sufficient rapidity, the whole series occupying less than twelve 
seconds. In this manner we find that our maximum perceptual 
unit of time is about twelve seconds. 

If at any time we endeavour to think of the present moment 
in contradistinction to the past or future we find that it is gone 
before we have had time to think. The present is always im- 
measurably short; it is indeed nothing but a moving boundary- 
line separating the past from the future. As a matter of experi- 
ence we include in our practical cognition of the present a short 
period of immediate past. The existing unit of time, as thus 
conceived, has received the name of “‘ the specious present ”’ 
(James), and the metronome has taught us that such an unit may 


TIME-PERCEPTION 43 


be as long as twelve or even fourteen seconds. These units are 
not separate from one another, but perpetually and constantly 
overlap. 

If, when we are engaged in conversation, the clock should 
happen to strike and occupy in striking less than one perceptual 
unit of time, we can usually say how many strokes occurred 
without having counted them or even attended to them; but 
we are unable to do this if the striking has occupied more than 
one perceptual unit of time, 7.e., more than twelve seconds. 
Indeed it sometimes happens under these circumstances that 
a person present remarks “‘ That clock only struck nine ’’ when 
the clock struck eleven. This affords an excellent practical 
illustration of the “‘ perceptual unit of time ”’. » 

Inasmuch as we are unable to give a name to each such per- 
ceptual unit, any given unit is identified with some incident 
(psychologically speaking, with some percept). In the absence 
of any percept of greater interest, we fix upon the fact that the 
hands of the clock point in certain directions. In this latter 
case the time-percept is clearly identified with a space-percept. 

When a mother tells us that a certain event took place “ the 
year that Willie was born”’, she is making an abstraction from 
the Willie’s-birth idea, the temporal relations of a percept being 
an essential part of the percept itself. Similarly the temporal 
relations of an idea are an essential part of the idea. In the case 
of a percept, there is always a feeling of ‘‘ now-ness ’’; and in the 
case of an idea, the revival of a specific percept, there is a feeling 
of “then-ness’’. The Willie’s-birth idea is incomplete if the 
feeling of “‘ then-ness”’ be abstracted from it, if temporal rela- 
tions be absent from the ideational content. Nowadays the War 
serves as a temporal point d’appu for everybody. 

This is one way in which an idea differs from a percept. An- 
other is that a perceptual image is clear and strong, whereas 
an ideational image, at least with most people, is indistinct and 
faint; and a third is that more effort of attention is required 
to obtain an ideational image than a perceptual one. It is 
much easier to see a dog than to picture (visualize) one. 


CONCEPTION. 


_ When from a number of percepts or ideas an abstraction of 
some quality or series of qualities is made and the qualities are 
recombined, the result is a concept. In this sense the colour 
“orange ’’ is a concept. The colour of the fruit is abstracted 
from a large number of orange-ideas, and the result of the 


44 MIND AND ITS DISORDERS. 


recombination of these colours is the concept of the colour 
“orange ’’: and if, from any number of orange-ideas we abstract 
all the qualities—the yellowness, roundness, sweetness, acidity, 
odour, coldness, softness etc., and recombine them, we have as 
a result a conceptual orange. Observe that an orange idea is 
the revived percept of a particular orange, and that an orange 
concept is a recombination of the qualities of a large number of 
revived orange percepts. 

It will also be noticed that the feeling of past time, the feeling 
of ‘‘ then-ness ”’ as we have called it, is not such an essential part 
of a concept as it is of anidea. This must not be construed into 
meaning that the absence of the feeling of “ then-ness ”’ is an 
essential attribute of a concept. The conception of concrete 
things is very closely related to ideation and therefore is fre- 
quently associated with a feeling of past time. When I form a 
concept from the various oranges which I have seen growing on 
the trees in Italy, the feeling of “‘ then-ness ”’ is insistent. 

Since conception is the abstraction and recombination of the 
qualities of a number of ideas, such abstractions as truth, virtue, 
health, happiness and honesty must be regarded as concepts. 
Irom such abstractions the feeling of past time is usually absent. 
If we abstract from our total number of ideas their spatial 
qualities and recombine them, we have as a result “‘ conceptual 
Space ’’; and if we abstract their temporal qualities and recom- 
bine them, we have as a result “conceptual Time’”’. ‘“‘ Bound- 
less Space ’’ and “‘ Eternity’ are examples of conceptual Space 
and conceptual Time. 


IDEATIONAL TYPE (OFTEN CALLED MEMORY-TYPE). 


We have seen that the idea of an object is made up of sensa- 
tions derived from various sense-modalities, visual, auditory, 
tactual, olfactory, gustatory and kinesthetic, as well as of 
sensations connected with the name of the object; and these 
again may be visual, auditory or kinesthetic (muscular sensa- 
tions connected with the pronunciation of the name). Some 
of them play a much greater part in the idea of an object than 
others; and the particular sense-modality which plays the greater 
part varies in different individuals. If a person’s idea of an 
orange is usually visual, his ideational type is visual; if olfactory, 
then his ideational type is olfactory; if he thinks of an orange 
in the terms of the written or printed word “ orange ’’, his idea- 
tional type is verbal-visual; if he thinks of it in terms of the 
sound of the spoken word “‘orange’’, his ideation is of the 


IDEATIONAL TYPES 45 


verbal-auditory type; and if he thinks of it in terms of the 
‘ kinesthetic equivalent’’, the word “‘orange’’, as it feels to 
him in his mouth when he says it, his ideation is of a verbal- 
motor type. 

The ideational type of most people is a combination of the 
above, with the “‘ visual’’ predominating. Next in order comes 
the verbal-motor type. Scientific men are as a rule bad visuals, 
because their thought is so much engaged in concepts and other 
abstractions. The author’s ideational type has quite distinctly 
changed from the visual to the verbal-motor. In trying to court 
sleep by the old device of watching sheep jump over a gate, the 
sheep and the gate used to be quite clear and distinct; but now 
it is quite impossible to see them. A faint outline of the middle 
of the gate may occasionally appear, but the sheep refuse to 
make their appearance. 

In order to prevent misconception it ought to be said, by 
way of conclusion, that the ideational type of a person appears 
to have no psychiatric importance. 


UNCONSCIOUS PERCEPTS. 


The conclusions of this chapter, as of the last, are the results 
of introspection and the subject-matter is a study of perceptual 
and ideational processes as they occur in phenomenal conscious- 
ness, but attention must again be directed to the unconscious. 
We have unconscious percepts, unavailable for introspection, 
as well as unconscious sensations; ideational content is uncon- 
sciously placed in such crude unconscious sensations as were 
mentioned at the end of the last chapter and percepts are thus 
formed unconsciously. If the clock in my room ceases to tick 
I look at it immediately to see what is amiss; thus showing that, 
although the tick was unnoticed, it was noticed in some uncon- 
scious way. A conversation beneath my window passes un- 
observed, but it is possible that it might be recalled under the 
influence of hypnotism. As you walk along a street you do not 
heed the touch of the many people who brush past; but, if you 
find on return that your watch has been stolen, you can probably 
name the very spot where it was taken and recall a host of 
hitherto unnoticed incidents that occurred there. 

In psycho-analysis it is a common experience for the patient 
to dream of some article, figure or design for which he can give 
no explanation until he suddenly discovers in the analyst’s con- 
sulting-room something which he had never consciously noticed 
before although it has formed the item in his dream. A patient 


46 MIND AND ITS DISORDERS 


of mine dreamed of a certain parcel, of which he could give 
every detail, including the way in which the knots in the string 
were tied. We could make nothing of it; but, on rising to 
depart, he suddenly exclaimed, “ Why, that’s the parcel in 
my dream !’’ A small brown-paper parcel had been lying on 
a shelf in my room for a couple of days, and his observation of 
the knots was correct in every particular, yet he had never 
consciously noticed the parcel before. This is not an unusual 
experience; it is common. . 

In this connection the post-hypnotic appreciation of time is 
of interest. Delbceuf, Milne Bramwell and others have suggested 
to patients under hypnosis that they would perform a given 
act, ¢.g., make a cross on a piece of paper, after a given interval, 
say, 3,400 minutes. This would be long after the hypnotic 
séance was over. In almost every case the suggestion was carried 
out impulsively at the correct time, without the patient knowing 
why the act was performed. 

There are certain observations which show that the initial 
stages of normal perception take place unconsciously and that 
the neurons concerned take an appreciable time to respond to 
a stimulus. For example, it sometimes happens to an ento- 
mologist, as he creeps along the side of the wall examining every 
inch for a specimen of a certain butterfly, that he suddenly 
realizes that he passed one four or five yards back; he returns 
and finds it at the very spot where he expected to do so. In 
this case the neural process is unconscious right up to the moment 
of perception. 

The reason for attaching importance to these unconscious 
processes will appear later. 


CHAPTER IV. 
ASSOCIATION OF IDEAS. 


IDEAS have been distinguished as simple and compound. When 
I think of a brick, I have a simple idea; when I think of a house, 
I have a compound idea comprising a number of brick-ideas, 
window-ideas etc.; and when I think of a village, I have a com- 
pound idea comprising a number of house-ideas. Now we have 
already observed that the simple idea never occurs in actual 
experience. <A brick is always perceived in connection with its 
temporal and spatial surroundings; and when a brick is recalled 
in ideation, ideas of other objects in spatial and temporal relation- 
ship with the brick tend to be recalled with it. If the qualities 
of the brick-idea be abstracted, they tend to become attached 
to other ideas with different temporal and spatial surroundings. 
For example, the redness of the brick may recall the redness 
of an omnibus going to the City. 

These are examples of the “ association of ideas’’, and such 
associations have been classified as follows: 


Associations by similarity. 
Associations by contiguity— 
(a) In space. 
; simultaneous associations. 
(>) In time te 
successive associations. 


An ordinary train of thought depends on the association of 
ideas. If I think of having attended a certain concert, I perhaps 
recall one of the songs which was about a bird; a similarity 
association may cause me to think of birds at the Zoological 
Gardens; a contiguity association arouses the idea of a friend 
who accompanied me on my last visit to the Gardens; a simi- 
larity association arouses the idea of Sherlock Holmes, and I 
think of crime etc. But why, instead of this train of thought, 
do I not form a continuous series of temporal-contiguity associa- 
tions and think of the friend with whom I walked home after the 
concert, of the letters I read when I entered the house, of my 

47 


48 MIND AND ITS DISORDERS 


breakfast next morning and so on, by a process which has been 
termed ‘‘ impartial redintegration ’’ ? In other words, what is 
it which determines the association of one idea rather than 
another with the idea already in consciousness ? This question 
has been answered by reference to experiments with the “ memory 
apparatus ”’. | 

The memory apparatus consists of an upright board with a 
couple of rectangular apertures side by side, through which 
pairs of cards may be exposed for short periods of time. In 
working with it the observer sits opposite the windows of the 
board while the experimenter works the cards. A_ typical 
experiment is carried out somewhat as follows: There are two 
series of cards for each window: one series is coloured, the other 
is white, with a letter of the alphabet printed on each card. 
Pairs of cards are presented to the observer’s gaze, é.g. : 


Red 
Purple 
Yellow 
Green 
Red 
Brown 
Yellow 
Violet 
Green 


ORORMK DOH Ss 


If a number of such pairs be presented to the observer and 
single members of the series be subsequently given for him to 
name the association he has formed with each of them, it is 
found that the association of one idea with another depends on: 
(1) The frequency and (2) the recency of their previous connec- 
tion, (3) the relative vividness of the previously connected ideas 
and consequently the degree of attention aroused by them and 
(4) the relative position in the series of the previously connected 
ideas; this depends also upon the degree of attention aroused. 
For example, in the above series it is found that the tendency 
to associate yellow with Q is strong on account of the frequency 
of the connection; green is associated with S rather than D, 
because the S-green connection is more recent; red is associated 
with M rather than Y, because of the prominent position of the 
M-red association (first); the L-brown association is a strong one, 
because of the vividness of the L-impression, the L arrests the 
attention. These laws are verified in actual experimental work 
by using a large number of such pair-series with a large number 
of observers and noting the frequency of right and wrong answers. 


RECOGNITION AND MEMORY 49 


This is necessitated by the fact that no mind is a tabula rasa, 
for everybody has had vivid experiences peculiar to himself 
which may cause deviation from the above rules. For example, 
the red-Y association of our series might well be more insistent 
than the red-M one in a soldier whose war experiences have led 
him to associate red with blood and Y with Ypres. | 

In applying these rules to the study of an ordinary train of 
thought it must not be forgotten that the vividness of an im- 
pression may be enhanced by the interest which attaches to it; 
in other words, by the attention paid to it. But for this fact, 
a logical train of thought would be an impossibility; all trains of 
ideas would follow a scatter-brained course, as in the example 
given above. 

It will readily be appreciated that in everyday mental life there 
are times when these laws conflict with one another, some com- 
bining to encourage one association and some another; so that 
the particular idea which comes into consciousness is that which 
—on balance—an individual's experiences favour most, especially 
those to which the greatest affect is or was or ought to have 
been attached. 


COGNITION, RECOGNITION, MEMORY AND IMAGINATION. 


The simplest example of association by similarity is the 
cognition or direct apprehension of an object. When I see a 
hat, its shape at once revives the concept “‘ hat ’’, and the article 
is at once cognized as a hat. When I look inside the hat and 
observe the initials ‘““ W. H. B. S.’’, I recognize the hat as mine. 
Recognition then is a simple example of association by conti- 
guity; but no sharp line can be drawn between cognition and 
recognition. When I turn a corner of the street and meet my 
friend Brown, it is difficult to decide whether I cognize him 
as Brown or recognize the object, which I have cognized as a 
man, as Brown, by the contiguity association of the familiar 
face with the man. Instances of recognition of this latter class 
(recognizing Brown) have been called “‘ immediate recognition ”’ 
in contradistinction to those of the former class (the recognition 
of the hat) which have been called ‘‘ mediate recognition ”’. 
Mediate recognition is in reality an “‘ association of percepts ”’. 

The process of recognition consists of three part-processes: 
firstly, there is a percept; secondly, the percept calls up by 
association secondary ideas of such percept having been pre- 
viously experienced in different temporal and spatial surround- 
ings; and, thirdly, there is a feeling of familiarity dependent, as 

4 


50 MIND AND ITS DISORDERS 


we shall see later, upon muscular and other organic sensations 
reflexly aroused. 

Memory differs from recognition in that the first part-process 
is the vevival of a percept or the presentation of an zdea. If, 
in the above analysis of recognition, the word “idea ”’ be sub- 
stituted for “ percept ’’, we have an analysis of memory into its 
part-processes. When I think of some past incident, there is a 
faint image of the incident (not necessarily a visual image); 
there is a feeling of the image having occurred previously and an 
accompanying emotional tone of familiarity. The image arising 
under these circumstances has been called the ““ memory-image ”’ ; 
all revived percepts are in reality memory-images. The form of 
memory, corresponding to mediate recognition and dependent 
on the association of ideas, is called “‘ associative memory ”’. 
Memory then stands in the same relationship to recognition as 
ideation stands to perception. 

When we tvy to remember something which does not easily 
come to mind, we endeavour to find associations. If, for ex- 
ample, we wish to remember the name of a patient, we pass his 
symptoms in review, try to visualize him, think of the town in 
which he lived—if possible—and of the name of his doctor, and 
perhaps we go through the alphabet in order to see which letters 
arouse an emotional tone of familiarity. Ultimately we may 
discover some association which recalls the name. On the other 
hand, we may not, and we fail in our quest. 

This brings us to the fact that forgetting is almost as common 
as remembering, and must therefore be considered as a normal 
mental function. It raises the question, ‘““ Why do we forget ?”’ 
whose answer is found by asking another question—‘‘ What do 
we forget ?’”’ This has been answered by the method of psycho- 
analysis, which is described in a later chapter. Psycho-analytic 
investigation has revealed that anything forgotten has invariably 
some unpleasant unconscious association. This does not usually 
mean that the thing itself is unpleasant. For example, a school- 
boy is asked by his mother to bring home a cake. He buys it, 
but unintentionally leaves it in the train or bus; not because he 
does not like cake, but because he has an objection (conscious or 
unconscious) to carrying paper parcels. The following instance 
occurred to the writer: He had accepted an invitation to dinner 
and was obsessed by the fear that he would forget it, so much so 
that he was careful to enter the engagement in every diary and 
on every almanac he had. The day arrived, and the engagement 
was forgotten. Subsequent analysis of the incident reminded 


FORGETTING 51 


him: that his would-be host, a charming person who willingly 
forgave the misdeed, had originally been introduced by a “ friend ”’ 
who had proved false. The unconscious mind was trying for a 
whole week to assert itself, and in the end succeeded. By a 
similar mechanism, although we never forget the death of a dear 
friend or relation, we do forget a host of minor events which 
occurred about the same time, whose recall would tend by the 
association of ideas to remind us of the painful incident and to 
revive our grief. Our conclusion is, then, that forgetting is a 
protective mechanism whereby the mind is shielded from un- 
pleasant memories. 

This mechanism undoubtedly plays an important part in 
determining our amnesia for the first four or five years of life. 
As we grow up, the ideas of having appeared naked before others, 
of having been bathed and handled by others, of having been 
cleansed after defecation, and so forth, become unacceptable to 
phenomenal consciousness and they are forgotten. As we shall 
see later, however, they are not lost, for infantile memories can 
often be recovered by psycho-analysis or hypnotism; they are 
merely repressed into the unconscious. 

Another possible reason why early infancy is not remembered 
is a physical one, viz., that many of the central association 
neurons are not completely myelinized until four years of age 
(Flechsig), and are therefore functionless. 

The psychology of failure in recognition is parallel with that 
of forgetting. We readily recognize a former patient, even after 
many years, in whose case we were brilliantly successful in 
diagnosis or treatment, and even those with whom we failed but 
gained knowledge thereby; but when we meet a former patient 
in whose case we failed and yet gained no knowledge thereby, 
he may appear to be a total stranger. 

Imagination bears the same relationship to recognition and 
memory as conception bears to perception and ideation. When 
we read an account of the upper reaches of the Amazon, we 
imagine the scene by the associative combination of various 
concepts of forests, rivers, men of colour etc., with various ideas 
of South American animals and plants derived from descriptions, 
pictures, museums, zoological and botanical gardens. The scene 
is imagined by the associative combination of these into a new 
concept. 

There are two varieties of imagination, viz., reproductive and 
constructive. They differ in the first part of the process. The 
above is an example of “‘ reproductive imagination ’’. Firstly, 


52 MIND AND ITS DISORDERS 


there is a percept (the printed pages of the book describing the 
scene) and secondly, the percept calls up various concepts and 
ideas, abstractions from which recombine into a new concept. 
If, instead of the primary perception, we have an associatively 
aroused idea, we have an example of “‘ constructive imagina- 
tion’’. This is the process which stands the poet, the novelist 
and the inventor in good stead. A®sop’s fables, Jules Verne’s 
stories, Coleridge’s ‘‘ Ancient Mariner”’ and the invention of the 
printing-press and the steam-engine are all examples of con- 
structive imagination. 


JUDGMENT AND REASONING. 


A judgment is formed when an abstraction is made from any 
percept, idea or concept, and the abstraction recombined or 
associated with the primary percept, idea or concept. In other 
words, a judgment is an association after disjunction. When we 
think of gold being yellow, we abstract the yellowness quality 
from the gold-concept and reassociate the yellowness with the 
gold. 

A judgment is therefore nothing more than a special form of 
association; the yellowness is merely associated with the gold 
instead of with daffodils, the skin of a Chinaman or what not. 

The verbal replica of a judgment is a proposition, 1.e., a 
sentence in which a predicate is affirmed or denied of a subject, 
a sentence in which “ it is asserted that some given subject does 
or does not possess some attribute, or that some attribute is or 
is not conjoined with some other attribute’ (J. S. Mill). The 
proposition corresponding to the above judgment is “ Gold is 
yellow ”’. 

Reasoning consists of a series of judgments (verbally, a series 
of propositions) related to one another, the last term of the 
series being a conclusion dependent, rightly or wrongly, upon 
the preceding judgments or propositions. The question of 
legitimacy of inferences made during a train of reasoning belongs 
to the art of logic, as also does the discrimination between true 
and false propositions. Logic teaches us how we ought to think; 
psychology tells us how we do think. 


Unconscious ASSOCIATIONS. 


If the mind be allowed to wander without conscious direction 
of the flow of thought, as, for example, during the act of going to 
sleep, and the current of ideas be observed by introspection, it 


UNCONSCIOUS ASSOCIATIONS 5 


will be noticed that here and there an incomprehensible jump 
occurs from one idea to another, apparently quite disconnected. 
If now the subject, probably the reader, in a second somewhat 
similar experiment, allows various associations to develop with 
each of the two apparently disconnected ideas separately, he will 
probably hit upon the connecting-link between the two, which 
never entered consciousness in the original train of thought. The 
- association of ideas was unconscious. 

Another method of discovering unconscious associations is by 
the word-association test, which consists of giving a series of 
stimulus commonplace words to each of which the patient or 
subject has to react by naming the first association or reaction- 
word which occurs to his mind. The subject will occasionally 
respond to a stimulus-word with a reaction-word having no 
obvious connection with the former, and he may even remark, 
“I do not know why I said that’”’. On closer investigation, it 
is found that there is a connection, and that the lack of coherence 
was only apparent. The connecting idea was unconscious. 

Reference has already been made to the common difficulty of 
remembering a name. Various efforts are made, but it is found 
impossible voluntarily to recall it; but, perhaps long afterwards, 
when one is thinking of something having no manifest connection 
with it, the name suddenly forces itself upon consciousness. The 
association of ideas in such a process is unconscious, and it is 
only by subsequent analysis that an association is discovered 
between the name and the content of consciousness preceding 
the moment of recall. 

Complexes.—Ideas are never isolated in the mind; they are 
apt to cluster round some particular trend of thought tending to 
emerge in some form of activity. Such a cluster is known as a 
“ constellation of ideas’’. The individual is sometimes totally 
unaware of some, or even all, of the ideas in such a group, 
although they are in his own mind. They are repressed into the 
unconscious, and can only be discovered by some process of 
mental analysis. Such unconscious constellations are known as 
“complexes ’’ and we shall have frequent occasion to refer to 
them in later stages. The association of ideas plays an all- 
important part in mental life and we shall find that complexes 
play an enormous role in the mentation of both the sane and 
the insane. 


CEA Re ie yc 
AFFECTION. 


THE word “affection ’’ is used by psychologists to mean the 
pleasant or unpleasant tone of feeling which accompanies 
sensation. 

Most persons find unsaturated and intermediate colours more 
pleasant to look upon than saturated colours; with some ob- 
servers the reverse is the case. Greys are more pleasant than 
pure white or black. Tones are more pleasing than noises, and 
tones of medium pitch than those of very high or very low pitch. 
Odours of fruit and flowers are more agreeable than those of 
decaying animal matter. Sweet and salt substances are generally 
more acceptable to taste than sour and bitter. Moderate warmth 
is more pleasant than extreme heat or cold. Painful sensations 
are almost invariably associated with a tone of unpleasantness. 
Sexual sensations are usually pleasant. Moderate muscular 
exercise is pleasant, while excessive muscular exertion and 
enforced rest are unpleasant; and, with regard to sensations in 
general, it may be noted that weak stimuli are as a rule more 
agreeable than strong ones. 

Although sensations are commonly accompanied by a tone of 
feeling, affection is not to be regarded as an attribute of sensa- 
tion. Affection is, in its essence, a superadded mental state 
of the individual who experiences a sensation. As I sit by the 
fire on a frosty day the warmth seems to be in the skin, but the 
pleasantness of the warmth is the way in which I experience it. 
Moreover, sensation is more localized than affection. If I knock 
my shin against a chair in the dark, the sensation is localized 
in my shin; but the unpleasantness of the pain pervades the’ 
whole of consciousness. Again, a tone of feeling tends gradually 
to disappear, to wear off, while the sensation remains practically 
unaltered. 

Sensation and affection differ in yet another way. If we. 
attend to a sensation, it grows clearer and more intense. If 
we attempt to attend to an affect, the tone of pleasantness or 
unpleasantness at once disappears. This will be better under- 

o4 


AFFECTION 55 


stood when we have considered the phenomena of attention. For 
the present, it may be noted that attention to the tone of feeling 
necessitates inattention to the sensation which gives rise to it. 
As previously stated, sensation and affect cannot be divorced 
from one another, and we shall soon learn that it is the all- 
important affect which dominates our conduct through life. 

The physical concomitants of affection have therefore been 
studied and, as a result, it has been shown: 

1. By the plethysmograph, that a positive tone of feeling 
(pleasantness) is accompanied by an increase of bodily volume 
(dilatation of arterioles) and a negative* tone (unpleasantness) 
by a decrease (contraction of arterioles). The latter is possibly 
due to adrenalin, since it has been ascertained by Cannon that 
such emotions as pain, fear and anger are accompanied by an 
increase of internal secretion by the adrenal bodies. 

2. By the sphygmograph, that a positive tone is accompanied 
by a decrease in pulse-frequency, a negative tone by an increase. T 
Some psychologists measure the degree of an emotion by the 
amount of increase of the pulse-rate, especially in response to 
certain stimulus words. Indeed, the existence of an emotion is 
sometimes detected by a change in the pulse-rate alone. 

3. By the pneumograph, that a positive tone is accompanied 
by deeper respiration, a negative by shallower. 

4. By the dynamometer, that a positive tone is accompanied 
by an increase of muscular power, a negative by a decrease. | 

5. By the automatograph (a scientific form of planchette), 
that a positive tone is accompanied by abduction of the arm, and 
a negative by adduction. 

6. By the galvanometer, that emotions alter the electrical 
conductivity of the body. 

These results indicate a general tendency on the part of the 
organism to reach out towards the pleasant and to withdraw from 
the unpleasant. A moment’s consideration will show that this 
is the whole nature and purpose of affection; pleasing things 
attract and unpleasing things repel the organism. In the scheme 
of evolution, affection is the inevitable sequel to the development 

* This statement is in accordance with German views. Titchener states 
the contrary. 

t Cannon has also determined an augmentation of the sugar content and 
of the coagulability of the blood in unpleasant emotions, both originated 
by enhanced adrenal activity. Although we are rather anticipating, 
it may here be suggested that the greater production of sugar supplies the 
muscles with energy required for defence or attack, and that the increased 


coagulability of the blood is preparatory to the healing of possible wounds 
in combat. 


56 MIND AND ITS DISORDERS 


of sensation and movement. It is the tone of pleasantness which 
attracts the organism to its food and other objects necessary to 
the maintenance of its life or to the perpetuation of its race. It 
is the tone of unpleasantness which repels from danger. If a 
race of hares should evolve which regarded the appearance of a 
greyhound with indifference, that race would very shortly come 
to an end. If a family of children were born who took pleasure 
in sitting on the fire, they would not live to perpetuate their 
species. And if a man develops a lasting revulsion from food, he 
dies unless the natural laws of evolution are counteracted. 

It has been observed that attention to an affection is an 
impossibility, and this observation might lead to the inference 
that introspection can render but little assistance in eluci- 
dating its psychology. We have, however, been using the 
phrase ‘‘ tone of feeling ’’ in discussing the nature of affection. 
By retrospection, which differs but slightly from and is in many 
cases the same thing as introspection, we find that the phrase 
“ tone of feeling ’’ is wellfounded. The affective tone of pleasure 
or pain is a feeling or sensation superadded to the sensation 
which gives rise to it; and since we have found that sensations 
arise from peripheral stimuli, it becomes our duty to look round 
and see if we can discover any stimuli which may be regarded 
as the cause of this superadded sensation. 

The experimental results obtained in the investigation of 
affective states by means of the plethysmograph, pneumograph, 
automatograph etc., supply the required information. We find 
that in affective states stimuli to muscular and circulatory 
sensations are at work in divers parts of the body. The in- 
ference is that these give the superadded sensations which con- 
stitute the feelings of pleasure and pain. The dilatation of 
arterioles, the increased pulse-frequency, the deepened respira- 
tion and the arm abduction are motor phenomena which take 
place involuntarily. Indeed, we should not have known that 
they occurred but for experimental observation. They are, 
therefore, to be regarded as reflexes. 

From the above considerations, therefore, we learn that the 
feelings of pleasure and pain are due to muscular and circulatory 
sensations, which are nothing more than a complicated reflex 
action, and that the intrinsic nature of these feelings has developed 
as a natural sequel to the struggle for existence. 


EMOTIONS | 57 


EmoTIoNs, PAssions, Moops AND TEMPERAMENTS 
(GENERICALLY TERMED AFFECTS). 


The tone of feeling which attaches to a percept is of a much 
more complex nature than that which attaches to a simple sensa- 
tion, and it has a very much larger number of varieties. These 
are known as the emotions. An emotion is the tone of feeling 
which attaches to a percept, idea or concept; and inasmuch as 
the colour of the emotion differs with almost every possible 
percept, idea and concept of things, people, incidents and situa- 
tions, a satisfactory classification of the emotions is practically 
an impossibility. The feeling of attraction towards people and 
things may take the form of interest, familiarity, intimacy, 
reverence or love. Repulsion may take the form of dislike, 
disgust, antipathy, contempt, repugnance, disdain, hatred or 
anger. Ideas of welfare may be associated with feelings of 
satisfaction, gratitude, contentment, joy, hope or anticipation; 
ideas of harm with feelings of sorrow, grief, dissatisfaction, 
resignation, despair, fright or horror. If the ideas are of the 
welfare or injury of others, we may have feelings of gratification, 
gladness, envy, jealousy, regret, care orsympathy. Yet all these 
take no account of such feelings as those of effort, misery, decision, 
defiance, pride, shame and mirth. Indeed, every mental opera- 
tion has its emotional element. Such processes as recognition, 
comparison, discrimination, judgment and reasoning have a 
characteristic feeling attached to each of them, and this should 
not be omitted in a complete description of any of these processes. 

In attempting a study of the emotions we are met with the 
same difficulty as in the study of affection; the emotion is gone 
as soon as attention is directed to it. By a careful series of 
retrospections, however, we can arrive at the conclusion that 
an emotion consists of a number of sensations and that these 
sensations are derived from the activities of certain muscles 
(voluntary and involuntary) and glands (sudorific, lachrymal, 
intestinal etc.). The activities of involuntary muscles give rise 
to certain circulatory changes, such as increased or diminished 
frequency of the pulse, as well as to local flushings and pallors.* 

* Sir Charles Sherrington has sought to exclude circulatory and other 
visceral changes from the physical basis of emotion. Choosing a dog which 
was especially liable to violent outbursts of rage, joy, disgust and other emo- 
tions; by appropriate spinal and vagal transection he removed completely 
all sensation from the viscera. Yet the dog continued to give evidence of 


emotion by retraction of the upper lip, pressing backward of the ears, 
growling etc. This experiment does not prove that visceral sensations, 


58 MIND AND ITS DISORDERS 


The more we investigate the matter, the more we become con- 
vinced that these sensations are the very essence of emotion. 
Let the reader conjure up some emotion and note the various 
sensations which he experiences in connection therewith. Then 
let him divest the emotional feeling of all these bodily sensations, 
and he will find that there is no part of emotional feeling left. 

The various activities which give rise to the emotions are also 
responsible for their expression. The expression of an emotion 
is that movement or complex of movements occurring in an 
individual which indicates to others the nature of his emotion. 

In the emotions accompanying pleasant ideas there is an 
increase of muscular tone and power, with a tendency to abduc- 
tion of the arms, a decrease of pulse-frequency with general 
dilatation of the arterioles, and an increase of the frequency and 
depth of respiration. In the emotions accompanying unpleasant 
ideas we have the reverse bodily conditions. This much we have 
already learned in our study of affection; but, in addition to these 
physical signs, there are many others in the various emotions, 
each complex of physical signs giving rise to that expression 
which is characteristic of the particular emotion. In anger 
there are contraction of the corrugatores superciliorum, fixation 
of the gaze, dilatation of the nostrils, tightening of the lips, 
grinding of the teeth, clenching of the fists, extension of the trunk 
and flushing of the face. In disdain there is contraction of the 
levator labii superioris aleque nasi. In fright the mouth and 
eyes are widely opened, there are extension of the trunk and 
limbs and pallor of the face. In suspicion there is rapid lateral 
oscillation of the eyes. In dissent there is lateral nodding of the 
head; in assent, antero-posterior nodding of the head. 

It has been pointed out by Darwin and others that all these 
apparently purposeless actions are the unconscious survivals of 
actions which previously have been of conscious service to 
ancestral organisms. For example, in anger the gaze would be 
fixed upon a dangerous enemy, the fists clenched and the teeth 
ground upon some portion of his flesh; the dilatation of the 
nostrils would then become a necessity for breathing. The 
disdainful contraction of the levator labii superioris aleeque nasi 
is the uncovering of the canine tooth preparatory to biting the 


as Sherrington suggests, contribute nothing to emotional feeling. The 
dog expressed emotion by and experienced it from contraction of its facial 
muscles, because spinal transection could not possibly interfere with these 
facial reactions; but there is no proof that the emotional feeling of the dog 
was not diminished by the removal of its visceral sensations. 


PASSIONS, MOODS AND TEMPERAMENTS 59 


object of disdain. Oscillation of the eyes in suspicion is the 
search for anticipated danger. The lateral nodding of the head 
in dissent is the survival of the movement with which the infant 
refuses the proffered breast; while the nodding of assent is the 
movement of acceptance of the breast. Fear, at least so far as 
its physical signs are concerned, is exhausted anger or passion. 

Emotional feelings, then, consist of a complex of sensations 

arising from these various activities. According to this view 
(the Lange-James theory) it is not the emotion which gives rise 
to the expression, but the expression which gives rise to the 
emotion. The truth of this assertion was appropriately referred 
by Professor James to numerous actors, who were asked whether 
they experienced the emotions which they portrayed upon the 
stage. The best actors appear to be unanimous in the verdict 
that they actually feel the emotion they portray, when they 
are acting an emotional part well. The experiences of the audi- 
ence are no less interesting. When a member of the audience 
feels that he is being too much overcome by the sadness of the 
situation on the stage, he extends the trunk, assumes a smile, 
takes a deep breath and surreptitiously wipes away the starting 
tear; by such means he dispels the emotion. And how often is 
an ill-timed merriment suppressed by assuming the expression, 
say, of attention. It requires, however, considerable effort to 
subdue a strong emotion; for emotions have a tendency to 
persist long after the ideas which aroused them have disappeared 
from consciousness (inertia of emotion). 

The conclusion is, therefore, that an emotion is a feeling com- 
pounded of sensations which arise in consequence of complex 
movements reflexly aroused by the situation (real or imaginary) 
in which the individual is placed. 

Many psychologists are unwilling to accept this theory, yet 
they have failed to discover the fallacy of it, if one exists. The 
best argument I know against it is that those patients who suffer 
from certain organic diseases of the nervous system which induce 
involuntary laughter are reported as stating that they do not 
feel the emotion of laughter; but these reports are unaccom- 
panied by any statement respecting other parts of the body. 
It may well be that painful persistent laughter induces motor, 
vasomotor and other reactions of annoyance elsewhere than in 
the face. 

Emotions have an inhibitory effect on the association of ideas 
and retard this process, which inhibition psychiatrists have to 
overcome in analyzing the mental life of a patient. 


60 MIND AND ITS DISORDERS 


Each emotion has its corresponding passion and mood, a 
passion being an intense emotion of short duration, and a mood 
a prolonged emotion of moderate intensity. Fury, anguish, 
terror and hilarity are the passions corresponding respectively 
to anger, sorrow, fear and joy; the corresponding moods are 
respectively chagrin, gloom, anxiety and happiness. 

Closely allied to the moods are the temperaments. For 
practical purposes, a temperament is to be regarded as a mood 
which lasts the greater part of a man’s life. It is a man’s tem- 
perament which is mainly responsible for the nature of the 
emotional tone aroused in him by any particular incident. The 
same incident will arouse different emotions in different indi- 
viduals. A similar incident will also induce different emotions 
in the same individual at different times, according to his already 
existing mood or emotion. 

Four temperaments are recognized: the sanguine, the choleric, 
the phlegmatic and the melancholic. The sanguine and the 
choleric are the temperaments characterized by rapidity of 
thought and ease of receptivity, the phlegmatic and melancholic 
by slowness of thought and receptivity. The choleric and the 
melancholic are characterized by greater depth of feeling than 
the sanguine and the phlegmatic. 


Temperaments. 
Shallow Feeling. Deep Feeling. 
Slow thought and re- © Phlegmatic Melancholic 
ceptivity | | 
2 (a 
Quick thought and re- Sanguine | Choleric 
ceptivity | | 


THE PHYSICAL BASIS OF EMOTION. 


There is evidence to show that the thalamic region plays an 
important rdle in the development of an emotion reflexly aroused. 
If a patient has a lesion of one optic thalamus, say the right, 
and you tell him a joke, he smiles on the right side of the face 
only; the smile does not occur on the left side. That this 
paralysis is not due to a lesion of the cortex or pyramidal tract 
is shown by the fact that the two sides of the face act equally 
when he assumes a smile. If, on the other hand, the patient has 


PHYSICAL BASIS OF EMOTION 61 


a lesion of the right Rolandic area, he smiles equally on the two 
sides in response to a joke; but an asswmed smile occurs on the 
right side only, volitional action being paralyzed on the left side. 

The observation of movements of expression occurring in the 
limbs is a more difficult matter in paralyzed patients; the 
physician has to rely upon an opportunity of watching the hand 
when the patient yawns. In paralysis of the hand due to some 
unilateral cortical lesion, the patient is unable to open the 
affected hand voluntarily; but if he yawns, the hand opens 
slightly. If, however, he has a lesion in the region of one optic 
thalamus, he can open the opposite hand voluntarily; but it 
does not always open involuntarily when he yawns. The con- 
clusion to be drawn from these observations is that the tracts 
subserving the motor element of emotion cross to the opposite 
side of the spinal cord. 

Now the only bundle which crosses from the mesencephalon 
to the opposite side of the cord is the rubro-spinal bundle of 
Monakow, that bundle which, as Held and Probst, and subse- 
quently Buzzard and Collier, have shown, arises on the ventral 
side of the red nucleus, decussates in Forel’s crossway with the 
corresponding bundle of the opposite side and is traceable to 
the region of the lateral tracts as far as the sacral region of the 
spinal cord. It connects the opposite nucleus ruber with the 
ventral horn of the cord. I submit, therefore, that Monakow’s 
bundle subserves the function of the motor element of emotion. 

We have also to consider the cortical portion of the system 
of motor neurons subserving the function of emotion. For this 
function a system of fibres is required to connect the cortex with 
the nucleus ruber, and such a system has been described by 
M. and Mme. Déjérine. The fibres originate from all parts of 
the cortex, especially the parietal lobe. They skirt the thalamus 
just above the radiations of the internal geniculate body, enter 
into the formation of the tegmentum, and reach the red nucleus 
at its antero-supero-external part. These fibres are to be 
regarded as the upper segment of the emotional motor system. 
Their intimate anatomical relationship with the thalamus easily 
accounts for the fact that that structure has hitherto been regarded 
as the physical basis of movements of expression. 

More primitive emotions, however, appear to be aroused by 
reflexes in lower levels of the nervous system. Goltz observed 
signs of hunger in dogs from which he had removed the cerebral 
hemispheres, and Sherrington, quoting Sternberg and Latzko, 
observes that the crying of the young infant has been noticed 


62 MIND AND ITS DISORDERS 


we 


in “‘hemicephalic’”’ (? anencephalic) children to be strong and 
of the usual character. 7 

Head and Holmes have shown that many crude sensations are 
apprehended by the thalamus without reference to the cerebral 
cortex and, moreover, that in lesions of the upper part of the 
thalamus the affective tone attaching to these sensations is 
increased. It would therefore appear that at this level there is 
a nervous arc from the thalamus to the red nucleus subserving 
the function of affective tone (in contradistinction to emotional 
tone), an arc of thalamo-rubral fibres probably included in the 
bundle of Meynert and under the tonic inhibitory control of 
cortico-thalamic neurons. The increased tone of affection in 
cases of tumor thalami would then be explained by the re- 
moval of this inhibition, the cortico-thalamic fibres having been 
destroyed by the lesion. 

It is of considerable interest that the cortico-rubro- gia 
motor system is the main representative of the pristine motor 
tract, by which in the lower vertebrates all motor impulses are 
transmitted. It has been demonstrated by Munzner and Wiener, 
Boyce and Warrington, Edinger and others that the pyramidal 
system of fibres does not exist in birds or in any of the lower 
vertebrates. In these animals the motor tract consists of 
cortico-thalamic and thalamo-spinal neurons only, the spinal 
fibres occupying the same relative position as the direct and 
crossed pyramidal system of mammals. In this connection 
it will also be remembered that in man the pyramidal tract is 
not completely myelinized until about the fifteenth month. 
Professor James has indicated the close relationship subsisting 
between emotions and instincts. They are both involuntary 
motor responses to percepts and ideas, and the only difference 
between them is that instincts bring the organism into more 
practical relation with the object of the percept or idea. .Now 
the lives of birds and lower vertebrates and the life of the human 
infant until it is about fifteen months old are practically little 
more than a mass of instinctive and emotional reactions; and it 
is not surprising to find that such reactions are, among the higher 
vertebrates, still dependent upon the functioning of the pristine 
nervous system. 

The neural process which takes place when an emotion occurs 
is then as follows: 

Starting from the stage at which a sensation is registered in 
one of the projection areas or a percept or idea formed in one of 
the association areas of the cortex, an impulse is transmitted to 


REPRESSED EMOTIONS 63 


the red nucleus by way of the cortico-rubral fibres, thence to the 
large motor cells of the lowest level by way of Monakow’s rubro- 
spinal (and presumably rubro-bulbar) fibres of the pristine motor 
system, and thence to the muscles of expression. Contraction of 
these muscles upon their spindles effects the transmission of 
muscle-sensations to the cortex by way of the ordinary sensory 
paths, and it is the particular combination of these sensations 
among themselves and with vasomotor sensations, which deter- 
mines the particular affective or emotional tone. 


UNCONSCIOUS EMOTION. 


It frequently happens, for reasons which will be set forth later, 
that the individual fails to react in the above manner to this or 
that experience. The emotion is then said to be “ repressed ’’. 
The reaction, not having taken place, leaves a certain amount 
of nervous energy (neurokyme) active, but ill-directed and 
unconscious. 

Every civilized being has innumerable selfish desires which he 
is unwilling to admit even to himself; they are therefore repressed 
into the unconscious. In terms of our theory, the subject 
voluntarily inhibits his natural cortico-rubro-spinal reactions. 
The most repressed of all desires are the sexual, and the result 
is that the unconscious, though chock-full of emotions of all sorts, 
is very largely sexual, and we shall find that these unconscious 
sexual desires play a very large rOle in the production of many 
symptoms and forms of mental disorder. 

Whenever a situation or incident tends to arouse an emotion 
which the subject does not wish to feel, such emotion is re- 
pressed into the unconscious and replaced in consciousness by its 
opposite. The old maid refuses to admit, even to herself, the 
slightest trace of sexual passion; it is therefore repressed and 
converted, in consciousness, into its opposite—prudery. A girl 
falls in love with a man who gives not the slightest indication 
that her love is reciprocated; she therefore represses her love 
into the unconscious and replaces it in the conscious by its 
opposite—hatred. Our brave soldiers in France almost daily 
saw such appalling sights as the limbs of a comrade being hurtled 
through the air by the explosion of a German shell. To react 
to such an experience every time with the natural emotion of 
horror would render trench-life intolerable; so the emotion was 
repressed into the unconscious, and replaced in consciousness 
by its opposite—laughter; and a side which did otherwise would 
lose the war. Those who failed to react at all, who neither 


64 MIND AND ITS DISORDERS 


laughed nor acknowledged to themselves a feeling of horror 
or fear, ultimately suffered from “ shell-shock’”’ in some form 
or other. Their unexpended neurokyme became a pathogenic 
force. It must be admitted that this is not a complete explana- 
tion of “‘shell-shock”’, for psycho-analysis of these patients 
reveals a much more deeply rooted complex which, in my ex- 
perience, is invariably the same in every one of them. 

Another important practical point about the psychology of 
emotion is that it is possible for an affect to remain conscious 
although the situation or idea which gave rise to it has been 
repressed—become unconscious; the result being that the affect 
remains unattached—floating free, so to speak, but ready to 
attach itself to any or every passing incident; or the affect may 
become permanently attached to some idea having little associa- 
tion with that which originated the emotion, “ transference of 
the affect’’. 

Both of these principles are illustrated by the fear which 
many women experience in the presence of a mouse or a cow. 
The cow’s horns are penetrating objects, her teats are rather 
obviously phallic in aspect, and the woman’s fear of a mouse is 
due to the fact that it “ might run up her clothes’’. Now the 
normal biological female affect towards the male organ is desire, 
but social and moral tendencies lead to repression of this emotion 
into the unconscious—its place in consciousness being taken by 
its opposite, viz., fear. Not only so, but this fear becomes 
dissociated from the idea of the male organ itself and becomes 
attached to such remote symbols of it as a cow and a mouse. 

The very strong objection which some people have to being in 
the dark or to standing on a height is usually traceable to some 
forgotten infantile experience, usually non-sexual, to which they 
failed to react at the time. By psycho-analysis such infantile 
memories may be revealed and revived in consciousness, with the 
result that the fear is dispelled. 


CHAPTER VI. 
ACTION. 


In this chapter we have to consider the psychical concomitants 
of movements of the organism. There are four forms of action, 
viz., reflex, instinctive, volitional and automatic. 


REFLEXES. 


Reflex actions are all carried out by the lowest level of the 
nervous system, the level in which, to use the language of Dr. 
Hughlings Jackson, muscles are first represented, and which 
extends from the oculo-motor nuclei to the tip of the spinal 
cord. Reflexes have no psychical concomitants; but, as we shall 
see later, they frequently serve the purpose of arousing conscious- 
ness by drawing our attention to a stimulus which might other- 
wise pass unnoticed. Reflexes are developed in accordance 
with the natural laws of evolution, which result in the survival 
of the fittest. If ever there existed a race of men without 
plantar reflexes, that race has long since died out from septicemia, 
tetanus and other results of treading on sharp stones etc. If 
ever there existed a race whose pupils did not react to light, that 
race has been destroyed long ago by its enemies whose pupillary 
reaction saved them from being blinded by the glare of the sun 
during combat. Sir Charles Sherrington, by his experiments on 
decerebrate cats and dogs, has taught us that many actions of 
great complexity, which hitherto have been considered to be of 
cerebral origin, are in reality of a reflex nature. For example, 
stimulation of one pinna of a spinal cat induces movements of the 
head and of all four limbs; while stimulation of one paw induces 
reflex movements of all four limbs and, in the case of a forepaw, 
of the head also. It is probable that even such a complex action 
as the crying of a new-born infant may be purely reflex. 


INSTINCTS. 


Instinctive action differs from reflex action in that it has 
psychical concomitants. It is practically perfect on the very 


first attempt, although there has been no previous education 
65 sy, 


66 MIND AND ITS DISORDERS 


in its performance, and it is of such a nature as to produce 
certain ends without foresight of those ends. At least there is 
no foresight on the first occasion of its accomplishment. A few 
instances will make this clear. 

Butterflies and moths invariably lay their eggs on or near the 
leaves of the plant which is the natural food of their young. 
These insects never knew their parents and they will never 
know their children; the butterfly therefore has no means of 
knowing what she is depositing when she lays her eggs near the 
food-plant of her caterpillar. Why does she do so? It is 
simply instinct; she cannot help it and the performance is known 
as an instinctive act. 

The first-year bird with a fertilized egg in her oviduct collects 
roots, moss, hair and feathers, and builds herself a nest; yet she 
can have.no idea that she is going to lay eggs therein; she has had 
no previous experience of such a performance. The plover lays 
her eggs in a ploughed field where they closely resemble the stones 
and are hence easily overlooked by predatory youths, but she 
has no means of knowing that her eggs will resemble stones. 
Further, when she has laid her eggs, there seems to be no possi- 
bility that she can have the remotest idea of their nature; yet 
she sits, and sits, and sits upon them until they are hatched. 
Why does the bird go through all this performance? Simply 
because she cannot help it; it is the inborn way of the bird; it is 
instinct. If evera bird existed that made no provision forits young, 
its race has died out in accordance with the laws of evolution. 

These are but a few examples, but it may be stated generally 
that some of the lower mammals, all birds, all vertebrates and 
perhaps all animals lower in the scale than birds, lead a purely 
instinctive life. Voluntary action, presently to be described, is 
peculiar to mammals. 

This fact is of the greatest interest when it is correlated with 
the anatomical differences, already mentioned in the chapter on 
the emotions, between the motor nervous system of mammals 
and that of birds and lower vertebrates. Mammals alone have 
a pyramidal tract, subserving volition. We shall see later that 
instinct is essentially the same thing as emotion; its physical 
basis is therefore the same as that of emotion, viz., the cortico- 
rubral system of neurons, which is the mammalian representa 
tive of the pristine motor system of the bird. 

Although mammals are endowed with a volitional motor 
system as well as an instinctive, they are quite as full of instincts 
as the lower vertebrates. Why does a cat run after a mouse? 


INSTINCTIVE ACTION 67 


Not because she is hungry and requires a meal, for she will run 
after the mouse whether she is hungry or not. It is for the same 
reason that many dogs will run after a bird; the likelihood of 
the bird forming a meal for the dog is exceedingly small. It is 
simply that these animals cannot help it; it is the instinct of 
pursuit. Why does the mouse run away from the cat? Not 
because it has any idea of death. Why does the Polar bear 
deliberately expose herself to the danger in which she sees her 
young ? Why does any animal seek its mate ? Why do many 
animals crowd together in flocks or herds? Simply because 
they cannot help it; it is their instinct. 

Instincts, like reflexes, have developed according to the laws 
of evolution. If ever there existed a species of swallow which 
did not migrate for the winter months, it has long since died 
out from the effects of cold; and if ever there existed a genus 
of bird which did not make provision for its young and sit on its 
eggs, that genus has in consequence ceased to exist. Instincts 
are developed for the benefit of the race. Occasionally, however, 
we come across an uncorrected instinct, as in the case of the 
lemming, which periodically attempts to migrate in its thousands 
from its native valleys in Norway to the long-submerged con- 
tinent of Atlantis: the result is that thousands of these animals 
are drowned in the sea, and their race runs the risk of becoming 
extinct. 

Man has been said to possess more instincts than any other 
animal. Innumerable are the occasions when he acts as he does 
for no other obvious reason than that he wishes so to act, the 
real reason being unconscious and buried in the past history of 
the race. Nevertheless, we shall find that these unconscious 
desires are the driving force of the whole of mental life. They 
constitute “ psychical energy ”’ or, as Jung has called it, “‘ horme”’. 
Psycho-sexual energy is known as libido. 

By the sixth week of life, eye movements are practically com- 
plete, and a child will instinctively converge for near objects. 
Passive attention develops, so that he will turn his head in the 
direction of a sound and reach out towards an object. Tactual 
space-perception, however, is yet incomplete, for at this age he 
will perhaps reach for the moon.* 

The seventh week is characterized for the development of the 
smile. . 

In the ninth week the instinct to handle objects is first observed, 
and by the eleventh week movements, which have hitherto 

* Some of these actions are possibly reflex. 


68 MIND AND ITS DISORDERS 


been apparently aimless, begin to assume a more purposeful 
aspect. 

The instinct to imitate sounds also makes its appearance about 
this time. Surprise and fear begin to develop, especially fear of 
change. This fear of change increases during the fourth month, 
until, in the fifth, we find it crystallized into an instinctive 
shrinking from strangers. 

Laughter shows itself at the beginning of the fourth month. 
During the fifth month the child develops the instinct to sit 
up and, about the end of that month, to carry objects to the 
mouth. 

The idea of distance, which a chick demonstrates as soon as it 
leaves the shell by pecking at morsels of food, does not appear 
in the human infant until the sixth month of life. The instinct 
to grasp objects appears in this month, but the child seems to 
have no idea of letting objects go until two months later. 

In the eighth month the child begins to take pleasure in 
making a noise, an interesting instinct often preserved through 
life. It will throw things on the floor for the pleasure of thus 
making a noise. 

The instinct of locomotion is usually first observed during the 
tenth month; this is followed in the eleventh month by the 
instinct to stand, the child constantly trying to get upon its 
feet; and during the twelfth month this develops into the walking 
instinct. 

During the ninth month the instinctive basis of language 
appears for the first time, and such sounds as “ kak-kak”’, 
“ba-ba’’ and “da-da”’ are uttered. These repetitive sounds 
have probably little or no meaning until about the fifteenth 
month, when “ dada ”’ and ‘“‘ bow-wow ’’ are uttered in association 
with the respective percepts ofa manandadog. The appellation 
“dada ’’ is not limited to the child’s father until the twenty-first 
month. But all these sounds are at first instinctive. 

Perhaps the sound “ kak-kak’”’ or “‘ack-ack”’ is the most 
striking example of instinctive language. It occurs in almost 
every child belonging to the Aryan race, and is an expression of 
disgust. The Hindoo word “ khaki’? means brown, the colour 
of dirt, dust or feeces.* I have frequently heard the same sound 
uttered by monkeys in the Zoo, when annoyed in any way by 
another monkey. Now the monkey has no voluntary language; 
this sound is therefore of instinctive origin. 

It is doubtful whether the mother’s or nurse’s interpretation 

* Cf. Ital. “cacare *’, to deftecate. 


INSTINCT 69 


’ 


of this sound as meaning ‘“‘ something nasty ”’ corresponds with 
the original meaning in the mind of the child, who regards its 
own feces—something created by itself—as important and even 
valuable matter. Indeed, when unobserved by adult eyes, 
children much older than this exhibit an interest in feces; and 
many stories unfit for the drawing-room demonstrate that this 
conscious interest does not always cease in riper years. 

The infantile interest in and tendency to play with feces is 
normally repressed into the unconscious. Notwithstanding, like 
other instincts, it is never lost; psycho-analysis reveals that it 
is sublimated in later life into all sorts of useful, social, moral 
and conventional activities. 

The sixteenth month is of great interest on account of the 
very earliest beginning of voluntary language. The child will 
say ‘ey’ (an attempted “ yes ’’) for assent; but the word “no ”’ 
is not used as a verbal negation until some months later. 

Language is first learned by instinctive imitation. During 
this month the child learns to say “ ta’’ when it is given any- 
thing; but it does so instinctively, for volition has not yet 
developed; myelinization of the pyramidal tract is only just 
being completed. If the child is told to say “ta” or “ ta-ta”’ 
it does not respond, for the reason that to say a word to order 
is a volitional act. A similar condition is frequently observed 
in patients with motor aphasia, who will answer “no” to a 
question, but cannot say “no ’’ when told to do so. 

Imitation, which is by no means limited to language, is itself 
aninstinct. Curiosity makes its appearance about the eighteenth 
month, and it is a remarkable fact that this instinct is almost 
always, if not invariably, initiated by some experience which— 
in adult life—would be regarded as being of a sexual nature. 
For example, a male child sees his mother’s breasts or a female 
child has an opportunity of seeing her father naked. Parents 
seldom realize how observant their babies are or how enormous 
is the permanent influence on their plastic minds of even the 
most trifling incidents; children are even permitted to observe 
coitus far more commonly than is usually supposed. Never- 
theless, the influence is not always harmful; for it is the sub- 
limation of this instinct of curiosity which lays the foundation 
of all investigation and research. 

In the nineteenth month the child shows signs of acquisitive- 
ness by clamouring for its brother’s or sister’s toys. 

In the twentieth month he shows a desire for social inter- 
course, the beginning of the gregarious or herd instinct. 


70 MIND AND ITS DISORDERS 


About the twenty-first month the instinct of cleanliness 
appears, not active cleanliness, but the tendency to avoid filth; 
and about the end of the second year, the child automatically 
ceases to be “‘ wet and dirty’’. By education, this may be 
achieved earlier. This is really one of the earliest “ repressions ” 
(vide p. 179)—the repression of the interest in excreta. 

The instinct of make-believe and play develops at the begin- 
ning of the third year. 

During the third year the child gets some idea “f time and has 
a definite concept of past and future. Accordingly conscious 
memory, on the one hand, and anticipation on the other, begin. 
The instinct of rebellion also makes its appearance. 

Destructiveness is an instinct which appears in the fifth year. 
The child often exhibits this by pulling off the legs and wings of 
flies; disinterested cruelty (sadism) is a primitive instinct. From 
this year onward the boy loves to tease others and he fights others 
with intent to do bodily harm. Here are the beginnings of the 
instinct to kill, not only the lower animals for food, but even 
human rivals. 

Constructiveness develops a couple of years later. If a six- 
year-old pulls his father’s watch to pieces, it is partly for the 
purpose of giving himself the subsequent pleasure of putting it 
together again. 

Emulation and rivalry appear about this time. Children of 
this age will, for example, vie with one another in collecting the 
largest bouquet of wild-flowers for their mother. 

The instinct to make collections of some kind usually shows 
itself, at least in boys, about the ninth or tenth year. 

The instinct to eat, which develops at a very early age, becomes 
especially prominent about this time. At this age the boy eats 
everything that is placed before him; there seems to be no 
possibility of satisfying his appetite and he takes the greatest 


interest in the “tuck-shop’’. I do not mean the sweet- 
shop, but the “tuck-shop’”’ where they sell such things as 
doughnuts. 


The period between twelve and fifteen is characterized by 
well-marked boastfulness and conceit. This usually develops 
into a feeling of power, general bzen-étre and, if it is not soon 
under volitional control, a state of simple mania. 

The instincts of hunting, fishing and shooting, stronger in man 
than in woman, for it is the man’s natural duty to provide food 
for his family, develop shortly after puberty. In civilized 
communities these last instincts usually find an outlet in open- 


INSTINCT aI 


air games. The study of general paralysis has led me to think 
that the spending of money is also instinctive at first. 

Parental love and jealousy are instincts which develop 
later. 

This by no means exhausts the list of instincts. There are 
many others, the date of whose first appearance I have been 
unable to fix, such as secretiveness, which causes people, even 
in the wilds of the country, to pull down their blinds at sunset; 
the instinct to comply with etiquette at table or in the ball-room, 
and other social, moral and ethical instincts. 

The reader has already said to himself: ‘‘ Love! Jealousy ! 
Modesty! These are emotions; these are not instincts.’”’ The 
objection holds good to a certain extent. Instinct may be 
regarded as the expression of an emotion (desire) which occurs in 
-response to a group of sensations, be they the sensations which 
a bird experiences when there is an egg in its cloaca, the visual 
sensations of a cat when she sees a mouse or the visual sensa- 
tions of a lover who sees his sweetheart walking with another 
man. The resulting movements are the expression of the accom- 
panying emotion. The only difference is that emotions are 
usually more restrained than instincts; instinctive action goes 
far enough to bring the organism into practical relationship 
with the outside world. | 

From disuse or constant inhibition many of the above instincts 
may atrophy. Similarly, if the normal stimulus to an instinct 
does not occur at the time when that instinct usually develops, 
the probability is that it will never appear. For example, 
a town-bred boy seldom acquires in after-life the instincts of 
hunting, fishing and shooting. 

Instinctive action on the occasion of its first occurrence is 
blind; but after a given instinctive act has occurred several times 
and its purpose has become clear, it can no longer be considered 
blind. We must therefore regard instinct as being implanted 
in us for the purpose of giving a series of cues to volition. The 
first attempt at a purely instinctive act is good; indeed it may be 
considered as perfect for all practical purposes although capable 
of improvement; but the first attempt at a purely volitional act 
is usually rather poor. 

Some authors have described impulse as a separate form of 
action. It is defined as action occurring without deliberation, 
immediately upon the presentation of a percept or idea. On 
examination of impulsive acts, however, it will be found that 
they can always be referred to some instinct. 


12 MIND AND iTS DISORDERS 


Classification of the Instinets—Every animal is designed 
primarily for the perpetuation of its species and secondarily 
for the preservation of its own life, and the instincts above con- 
sidered are nearly all subservient to one of these aims. Those 
which are not are referable to sociability, gregariousness or the 
herd instinct, to be examined presently; while a few may be 
ascribed to two or more of the master instincts. For example, 
modesty in dress may be assigned to the sex and herd instincts, 
modesty in eating to the self-preservation and herd instincts. 
Indeed, psychologists have deemed it wise to separate from the 
self-preservation instinct a special instinct of self-nutrition; so 
that we finally classify the instincts under four headings, viz., 
nutrition, self-preservation, sex and society. The word“ society ” 
is here used as applicable to man; gregariousness of animals 
generally, including man, is known as the “ herd instinct ”’. 

Self-nutrition is indisputably the first instinct to show itself 
in the new-born child. It is stimulated either by hunger or | 
appetite; the former being an unpleasant sensation demanding 
relief, while the latter is a pleasurable desire. It is at least 
doubtful whether a baby sucks its mother’s breast because it is 
hungry; it is more probable that its desire depends on the mere 
pleasure of sucking, which is inhibited only by the sense of 
surfeit. 

Later, when the child has reached an age when it can choose 
between one kind of food and another, the choice is determined 
by taste and flavour memories. Children usually dislike fat but 
like sweets, such likes and dislikes having been implanted in 
accordance with the needs of the organism. Contrary to popular 
notions, sugar 1s an important food for the young, while very 
little fat is required to satisfy their physiological needs. The 
great increase of appetite during the pubertal period, especially 
in males, is worth noting. 

The regular ordering of meals is a matter of custom, arising 
from convenience, and varies in different countries, and the 
instinct to go to a meal at a specified hour must be regarded as 
more social than nutritional. 

The instinct of self-preservation shows itself during the early 
helpless years of life only by crying (for help) when the child 
experiences pain or fear. As he grows older and ultimately 
becomes an adult, he develops such instincts as courage, pug- 
nacity, cruelty, revenge, deceit and dissimulation for purposes of 
self-preservation or self-advancement, which is the same thing. 

Contrary to popular belief, the foundations of the sexual 


THE SEXUAL INSTINCT 73 


instinct are laid in early infancy, just like those of other instincts. 
This fact is at first rather distasteful to our more refined nature, 
which likes to think of the child as “ pure’ and asexual; but it 
is well known to many intelligent observers of children, not 
excepting mothers, is acknowledged by the younger generation 
of physicians who specialize in the diseases of children and is 
demonstrated by the psycho-analytic investigation of hundreds 
of adult patients. 

The young child loves to manipulate its own body in a variety 
of ways, such as thumb-sucking, nose-picking, nail-biting, rub- 
bing the thighs together and rubbing its breasts and abdomen 
with its hands when naked. Even masturbation is common, 
and I have met with it as early as the ninth month. This is a 
stage of “ autoerotism ”’ 

Of course the child has not the faintest idea of sexuality as 
understood by the adult, but it is probable that during infancy 
every sensory stimulus has some sexual significance. This 
notion will be more easily comprehended when it is reflected 
that, even in adult life, the sexual instinct may be aroused 
through many of the sense-organs; for example, the eye (when 
_ seeing a beautiful face or figure), the ear (when hearing a beautiful 
voice or the rustle of a dress), the nose (when smelling certain 
odours characteristic of the opposite sex) and the skin (when 
feeling the skin of a member of the opposite sex, or even, in some 
people, in experiencing certain painful stimuli). 

It should be explained that the sexual emotion includes much 
more than direct or reflex genital stimulation. Indeed, this 
does not necessarily occur in most of the above situations. 
Sexual emotion includes attraction, friendliness, ideal love and 
many pleasurable thrills quite unconnected with and irrespective 
of genital excitation. 

As has just been said, a sensory stimulus to the infantile sexual 
instinct may, during the earliest months, be given through any 
part of the cutaneous surface; but, very shortly after, the element 
of sexuality appears to be concentrated in four chief areas—the 
mouth, the inner surface of the thighs, the anus and the neck of 
the bladder. These are the four primary “ erogenous zones ”’ of 
Freud. I think he might have added a fifth—viz., the breasts, 
at any rate in females. Their erogenous character in females 
persists into adult life. 

To give detailed evidence respecting the erogenous zones would 
unfortunately encumber a manual of this kind too much, and we 
must be content with a mere hint as to the nature of the evidence. 


a 


74 MIND AND ITS DISORDERS 


The mouth is first used for sucking the breast, and medical 
psychologists discern something of the nature of an orgasm when 
a satisfied baby flushes, leaves the breast and sinks into slumber. 
Thumb-suckers tend to manipulate or rub their breasts during 
their pleasure-sucking. The symbolism of kissing need scarcely 
be mentioned; but it is not generally known that energetic 
suckers in infancy are very fond of kissing in later life. 

Pleasure obtained by rubbing the thighs together is frequently 
observed in quite young infants, especially in girls. 

Anal eroticism is chiefly noticed in young children who volun- 
tarily retain their faeces in order to obtain what is for them 
a pleasant sensation of violent muscular contractions necessi- 
tating expulsion, in spite of the accompanying pain. This 
desire is nearly always repressed in later infancy, but it may be a 
factor in the constipation and certain other symptoms of some 
neurotics in later life. Psycho-analysis reveals this instinct to 
retain the feces to be the first attempt at economy, for such 
persons invariably grow up thrifty and methodical, and it is 
remarkable how frequently it is found during a psycho-analysis 
that faeces symbolizes money. Incidentally it is also to be noted 
that anal erotics have their own secret ceremonials in the w.c. 
It is, of course, natural that the child should object to the grati- 
fication of its desires being stigmatized by its nurse as a “‘ mess ”’; 
but Nature appears to have provided for special excitation of 
the anal area by periodical soiling and subsequent cleansing. 

The neck of the bladder is demonstrated to be an erogenous 
zone by the discovery that enuresis nocturna, except perhaps 
when it is caused by idiopathic epilepsy, represents a pollution 
corresponding to a sexual dream, even in cases of adherent 
prepuce and the like. Similarly a full bladder in an adult is 
liable to cause an erection during sleep. 

During the first two years of life the human infant seeks 
pleasurable gratification by stimulating various parts of its own 
body (self-love or autoerotism), but this is repressed and for- 
gotten during the dawn of the moral instinct in the third and 
fourth year, with its constituent feelings of shame, loathing and 
disgust, and later by the sublimation of the infantile sexuality 
into useful cultural and social ends. Should adversity befall 
this sublimating process, it lays the foundations of subsequent 
neurosis. 

During the fifth and sixth years the normal child seeks to love 
somebody other than itself, usually the person with whom it 
is brought most into contact—the mother, the nurse or their 


THE SEXUAL INSTINCT iis 


surrogates. It is to be observed, however, that the boy loves 
his mother the more and the girl her father, unless the behaviour 
of the parent of the opposite sex estranges the child. It seems 
probable that the greater frequency of homosexuality among 
women, whether acknowledged or repressed, may be due partly 
to the fact that the father, being the wage-earner, plays a less 
important part in the home circle. 

The chief mental characteristic of puberty, with its numerous 
physical manifestations, is the erection of incest barriers whereby 
love for the parents becomes gradually weakened and the subject 
during adolescence becomes attracted by persons of his or her 
own age outside the family circle, but ultimately of the opposite 
sex. More than this, the favourite parent usually serves as an 
unconscious pattern for the future mate. Boys are attracted by 
some girl resembling their mother and girls bya boy resembling 
their father, at least in some mental or physical characteristic 
which has appealed to them. 

The normal development of the sexual instinct, as above 
outlined, has been elucidated and confirmed by the psycho- 
analytic investigation of hundreds, probably thousands, of cases; 
but I fear that my endeavour to be brief and to pay due regard 
to the sense of proportion may engender scepticism and leave 
the student unconvinced. In many instances his own psychical 
constitution or “‘ make-up ’”’ may be an unconscious cause of 
his opposition to these truths. In such situations the critic’s 
own self-analysis can alone convince him, perhaps with his 
subsequent psycho-analysis of other people. 

Those readers who are unfamiliar with modern psychology 
will probably complain that too much attention has here been 
paid to the sexual instinct. To such it must be explained that a 
detailed study of this instinct is demanded, not so much by its 
complexity as by the fact, which will appear later, that it plays 
the most important rdle in the etiology of the neuroses and 
psychoses. 

Its importance, however, in common with that of the other 
primitive instincts, pales before the last instinct-group we have 
to discuss—viz., the ego-instincts. 

We have to recognize that man is a gregarious animal—indeed, 
the most gregarious animal there is, with his congregation into 
towns and cities, his innumerable social institutions and organi- 
zations, cliques, sets, classes, sects, unions, societies, associations, 
committees, clubs, municipalities, armies, parliaments, nations, 
empires and what not. Man, being more dependent upon com- 


76 MIND AND ITS DISORDERS 


munal life than any other animal, is miserable by himself, and 
his faculty of speech, peculiar to him alone among ali animals, 
becomes useless when he is alone. Asa matter of fact, language 
is nothing more than the final outcome of super-gregariousness. 

The advantage of gregariousness is that it ensures homogeneity 
of the herd and impels its constituent units to act in concert. 
This is of the utmost importance in hunting and warfare for 
example, for it is clear that the prey or enemy would be more 
easily vanquished by a large number than by a single unit. 
Homogeneity of a herd is secured by an inherent impulse in each 
individual unit to act in the same manner as his fellows. This 
herd instinct, like other instincts, is maintained by natural 
selection; for departure from the customs of the herd deprives 
the individual of the advantages of gregariousness, even if he 
escapes immediate death for his pains. 

Every herd has habits and customs of its own, but the par- 
ticular herd which concerns us now is that of civilized man, and 
it behoves us to inquire what features of human conduct are 
determined by the desire to conform with the habits of his fellows. 
For our present purpose the habits of even the savage races of 
mankind are of no moment. 

Clearly self-preservation and the gratification of nutritional 
and sexual desires are not primarily undertaken with the intent 
of pleasing one’s fellows, although it must be admitted that the 
herd instinct is occasionally brought into play for purposes of 
self-preservation, especially in time of war; that dining in com- 
pany is a recognized custom, because it is more agreeable than 
a solitary meal; and even that sexual orgies are occasionally 
arranged among the dissolute. The herd instinct in man is so 
strong that it pervades even his personal instincts. 

But what are the present-day customs of civilized man which 
are referable to his herd instinct ? In seeking an answer our 
thoughts naturally turn to such topics as Art, Science and 
Literature. Literature has its basis, of course, in language, the 
prerogative of man; but it is questionable whether man can 
arrogate all Science and Art to himself in view of the activities 
of the bower-bird, certain song-birds, the trap-door and other 
spiders and the beaver—all, be it observed, non-gregarious 
animals. Moreover, the artistic productions, scientific dis- 
coveries and literary efforts of man are individual endeavours to 
obtain a livelihood or, at best, an outlet for personal energy or 
horme. Intrinsically there is not the slightest gregarious element 
about them. Science, the impartial search for truth, would 


THE HERD INSTINCT fi 


indeed be vitiated by any attempt to please the community; for 
it is a matter of common experience among scientific investi- 
gators that any new discovery which tends to correct traditional 
belief, however erroneous, instantly receives antagonistic criti- 
cism and frequently scurrilous abuse. Literature and Art also 
have to abide by certain conventions of the human herd. 

The essential bases of human conventions are tabulated in the 
ten commandments of Moses, and we are given a more modern 
idealistic interpretation of these in Christ’s Sermon on the Mount. 
Although very few of us act strictly up to the principles of sym- 
pathy and self-effacement therein enunciated, we would all be 
prepared to accept them as ideal rules of conduct and to de- 
nounce antipathy and self-assertion as antisocial. Freud has 
called them the “ ego-ideals ’’ and speaks of the desire to act 
up to them as the “ ego-instinct ”’ 

On the other hand, we are faced by the patent facts that people 
sometimes give offence to one another of set purpose, rejoice in 
gossip, scandal, guile, deceit, trickery and fraud, and even in- 
dulge by thought, word or secret deed in many varieties of sexual 
debauch. All such thoughts and actions clearly originate from 
_ the primitive animal personal instincts of the subject and are 
inharmonious with his ego-instinct, which is never dead, even 
in the basest criminal; they therefore tend ultimately to cause 
intrapsychic conflict. Should the subject fail to admit to him- 
self that he is immoral, as frequently happens, he may even 
forget that his offence was ever committed: in psychological 
language, it is repressed into the unconscious. 

In view of many of the above eonsiderations it need scarcely 
be urged. that desire to comply with the wishes and customs 
of human society is a true instinct inborn in each individual, 
although its manifestations do not appear for some years. 
Modern psychological investigation confirms this fact; for it is 
quite frequently elicited that a patient has, for example, ex- 
perienced a sense of shame or modesty as early as two years of 
age on being observed naked by a stranger. But why? What 
harm is there in being seen naked? There is no conscious 
reason for it, and some primitive yet perfectly moral races of 
nrankind go about naked without detriment. We can only say 
that it is an instinct, the significance of which is shown and its 
origin symbolically given in the story of “the Fall” in the 
Garden of Eden, after which our first parents are said to have 
““made themselves aprons’’. The inner hidden meaning of this 
narrative will not escape the student of psychology. 


78 MIND AND ITS DISORDERS 


Our conclusion is, then, that the chief characteristic of civilized 
man is that he is moral, which means that he tends to repress 
his personal instincts in order to comply with the wishes and 
ordained customs of his fellows. This applies especially to his 
sexual instinct, for common talk identifies “‘ morality ’’ with 
repression of sexual desire rather than abstention from thoughts 
or acts of murder, theft or falsehood. 

We must, therefore, in spite of all sentiment, face the fact 
that the chief characteristic of human psychology is that man, 
as a herd, is opposed to all ideas and thoughts respecting sex. 
So strong is this peculiarity that even many doctors, who pre- 
sumably regard themselves as scientific men, consider the strictly 
scientific study of sexual matters to be improper. Gynecologists 
suffered for many years, specialists in venereal disease are still 
rather derided, but psycho-analysts are roundly reviled as 
immoral. 


VOLITION. 


Voluntary action is that which occurs after deliberation, the 
individual making a choice between one action and another or 
between action and inaction. As long as indecision lasts there 
is a conflict of motives, which we call deliberation ; and as long 
as deliberation lasts inaction is the result. 

The final decision to act is reached in one of two ways. In the 
first, all the conflicting motives have been considered, a con- 
clusion formed as to what is the best thing to do and we do it. 
In the second, deliberation is cut short and decision is forced 
upon us before we have considered all the evidence. ‘“‘ The 
house is on fire! For God’s sake, do something! It matters 
not whether you fetch a bucket of water or run to the fire-station 
or get the people out of the house; but act at once without 
further deliberation.’’ Again: “ Which boot shall be put on 
first ? It matters not; deliberate no longer, but act at once or 
the day will be gone.”’ The latter form of action is probably 
the more common of the two. 

This appears at first sight to be all very simple; but we have 
to realize, on the one hand, that it must be exceedingly seldom 
that all the conflicting motives to action or inaction come to 
mind (enter consciousness) and, on the other, that the selection 
of even precipitate action must have some sort of driving force 
behind it. Such considerations force us to the conclusion that 
unconscious factors must be at work. 


VOLUNTARY ACTION 79 


Every action we perform is determined by the existing cir- 
cumstances and environment of the moment lus an enormous 
number of previous experiences, either remembered or forgotten, 
which bear upon the situation. Moreover, even the most 
voluntary act is much more determined by unconscious trends 
and motives than by conscious deliberation. In fact, every 
action—even the most voluntary—is the only one which could 
possibly be executed by a given individual under such circum- 
stances at that moment. This is the scientific doctrine of 
“psychical determinism ’”’, which is totally opposed to the 
popular notion of ‘‘ free will’. There is abundant evidence 
among modern psychological investigations to justify this doc- 
trine, but it would lead us too far afield to discuss the matter 
further at present, and the student must defer his judgment until 
he has acquired some familiarity with unconscious mechanisms. 

Movement itself unless inhibited is the inevitable sequel to 
the idea of movement; this is shown by introspection. If the 
reader will form a vivid idea of some movement (for example, 
getting up to open the door) he will find that the muscles neces- 
sary to the movement at once begin to contract; and he will 
_ actually cross the room unless the action is inhibited by the 
thought that he is only performing an experiment. 

Among the enthusiastic crowds which attend football matches, 
it is quite a frequent occurrence for some member of the crowd 
to receive a violent kick from an onlooker behind him when one 
of the players is kicking the ball. Such an onlooker forms a 
vivid idea of kicking the ball himself and the idea sets free the 
movement. 

We see then that volitional action originates in ideation, and 
we must infer that its physical basis is in the ideational centres, 
that is to say, in the cortex cerebri. From the study of pre- 
frontal tumours, it has been found that the ideomotor centres, 
where movement-ideas arise, are situated in the left prefrontal 
lobe. The left prefrontal lobe must therefore be regarded as 
the physical basis of volition. In the above instance the idea 
of kicking is formed firstly in the visual perceptual areas, near 
the occipital lobes, and secondly in the motor ideational area of 
the left prefrontal lobe. 

The diagram of the cerebral centres of movement on p. 32 is 
adapted from Griinbaum and Sherrington’s work on the brain 
of the chimpanzee and from other diagrams. 

The dawn of volition, including voluntary language, occurs 
about the age of seventeen months. Volition continues to 


80 MIND AND ITS DISORDERS 


develop at least up to thirty years 6f age and perhaps much 
later. 

I have said that the function of instinct is to give the cue to 
volition. In other words, the pyramidal system tends to take 
over some of the work of the cortico-rubral system. In this 
way volition acquires control of instinct; and the essential 
feature of a man with a strong and stable personality and a fine 
character is that he has complete control of his instincts. 

Inaction arises from one of five causes: (a) A generally in- 
attentive condition of consciousness (day-dreaming); (b) absence 
from the ideas in consciousness of anything to suggest the idea 
of movement; (c) equal strength of the motives for several actions, 
deliberation being still in progress; (d) inhibition of action by 
some strong emotion, such as fear; and (e) the conclusion that 
inaction is more advantageous than action. 


AUTOMATIC ACTION. 


Automatic action is action which at one time in the history 
of the individual has been volitional but, owing to the frequency 
with which the particular act has been performed, is now carried 
out without psychical concomitants and is relegated to the 
subconscious. Walking, winding one’s watch, turning out the 
light when one goes to bed, and turning over the pages of a book 
are typical automatic actions. 

The favourite example is a practised pianist who can play a 
piece of music while he holds a conversation on some topic quite 
unconnected with the music and meanwhile pays no heed to 
the movements of his fingers. Such phenomena as these illus- 
trate the ease with which the nervous system forms a “ habit ”’. 

It has been said that “‘ Habit makes easy’. Not only is this 
the case, but it is also true that it is extremely difficult to free 
oneself from a habit, at least after thirty years of age. 

There are two differences between a voluntary and an auto- 
matic act. One is that a voluntary act necessitates attention 
to its performance while an automatic one scarcely arouses 
phenomenal consciousness. The other is that a movement-idea 
precedes a voluntary act, but not an automatic act. 

Now in advanced cases of senile dementia, voluntary and 
automatic actions are in abeyance, although there is no true 
paralysis indicative of damage to or atrophy of the Rolandic 
areas of the cortex. In such cases there is atrophy of both 
frontal lobes, but no affection of the precentral gyri. It seems 


HABIT Sr 


therefore reasonable to conclude that the physical basis of both 
volitional and automatic action is situated in the prefrontal lobes. 

Why is it that attention is not aroused by the performance of 
an automatic act; except, sometimes subsequently, when one 
finds that one has acted inappropriately, e.g., wound up one’s 
watch when changing into evening dress ? 

In the study of automatic action we are brought face to face 
with the fact that some cortical cerebration takes place without 
awakening consciousness; it is unconscious. Now it is well 
known that synaptic resistance is permanently lowered whenever 
that resistance is overcome, and therefore that frequent over- 
coming of that resistance must finally reduce it almost to ml, 
thus creating a tendency for the particular interneuronal con- 
nections to occur again. But how are we to explain the fact 
that the consciousness of frequently repeated actions gradually 
sinks into the background ? 

There need be no difficulty in answering this question. The 
phenomenon is self-explanatory; it demonstrates the fact that 
consciousness is mainly aroused by the formation of unusual 
interneuronal associations. 

No misconception need arise from this popular but some- 
what erroneous use of the word “consciousness’’. When a 
person says, “I did it unconsciously ’’, he does not mean that 
he was unconscious at the time that he did it; he means that 
he did it without paying any attention to the action. The 
conclusion, therefore, at which we have arrived is that “ atten- 
tion’’ is aroused by the formation of unusual interneuronal 
associations, by the overcoming of synaptic resistance where 
that resistance is still high, while some cortical cerebration may 
occur independently of any activity of the “attention ’’. When 
we say that the attention is aroused by the formation of unusual 
interneuronal associations, we are only stating in another form 
a truth which will be repeated in the chapter on Attention, viz., 
that the suddenness’ of a stimulus is a character which causes 
it to engage our attention, and suddenness is nothing more or less 
than “‘ non-associatedness’’. Inasmuch as attention plays an 
important part in determining the remembrance of any particular 
idea, automatic acts are remembered with difficulty. 


THE REACTION EXPERIMENT. 


Action has been reduced to its laboratory form in the so-called 
reaction experiments. The essential piece of apparatus for the 


estimation of reaction-time is a “ chronoscope”’ of some kind. 
6 


82 MIND AND ITS DISORDERS 


This is an arrangement by which time can be measured to a 
thousandth of a second and is so adjusted in connection with 
other apparatus that the time may be measured between the 
giving of a stimulus to sensation and the motor reaction of a 
subject in response to the stimulus, which reaction consists of 
his pressing a button (electric or otherwise) also in connection 
with the chronoscope. An ordinary physiological drum with 
a tuning-fork might serve the purpose, but the noise of the 
tuning-fork is rather distracting to the subject. 3 

The apparatus is used in many ways. In the natural reaction 
a stimulus is given to vision, touch, hearing, smell or taste, 
and the subject presses the button as soon as he experiences 
the sensation. The sensorial reaction is similar, but in this 
case the subject is required to pay special attention to the 
character of the stimulus and resulting sensation. In the 
muscular reaction special attention is given to the move- 
ment. The experiment may be modified in many ways; 
for example, the subject may or may not be warned by 
the experimenter that he is going to give a stimulus; a 
couple of seconds before the stimulus is given the experimenter 
may say “Ready’’ or ““Now’’. These modifications of the 
attention make considerable difference in the reaction-times. 
Here are some figures: 


Touch. Vision. Hearing. 
Second. Second. Second. 
Natural ee =i ie. . O'12—O°18 O*19—0°22 O*I4—0°19 
», (without warning) ie es 0°25 — —— 
Sensorial .. “- Bh oe O-21 0°27 0°23 
Muscular .. - ip v2 ay? Or1l 0-18 OrI2 


The variation in these results has more bearing upon the 
phenomena of attention than upon those of action. All that we 
learn from them is that a movement is released more rapidly if 
attention be directed to it. Variations in the natural reaction- 
time depend upon differences in the ideational type of different 
individuals; some types are more motor, visual or auditory 
than others. 

The reaction experiment can be varied ad infinitum. For 
example, it may be used to demonstrate that it takes longer to 
react with the foot than with the hand, longer still to react with 
the whole body as in making the start fora race, and it has been 
found that the reaction-time of long-distance runners is longer 
than that of sprinters. 

Now all these data may be very interesting, but they teach us 


THE REACTION EXPERIMENT 83 


~ 


little about the psychology of action if the reaction experiment 
is regarded as an end in itself. If, however, it be used as a means 
of introspecting action in its laboratory form, it is found to 
confirm the conclusions at which we have already arrived by 
cruder methods of investigation. When a reaction experiment 
is performed the subject should give the results of an intro- 
spection during the proceeding. If he be a practised observer 
his introspection will be something like this: 

Muscular Reaction.—‘ I had a strain sensation extending from 
the elbow to the finger. I had a vivid idea of the movement 
which I was about to perform and to which my attention was 
directed. I scarcely noticed the stimulus, but felt that it was 
a relief to move.” 

Sensorial Reaction.—‘* My attention was wholly directed to 
the stimulus; (perhaps) I was afraid that I should react to a 
false stimulus; I then had a visual idea of my own movement 
and of the apparatus.”’ 

The former is, perhaps, impulsive action in laboratory form; 
the latter is “‘ action after deliberation’’ in its simplest form. 
This is, however, more characteristically represented in the 
laboratory by the “ discrimination reaction’’. In this experi- 
ment the subject is required to react to one stimulus only, 
although several may be given; for example, he may be required 
to react to the colour blue only although he may receive the 
stimuli of other colours. As a matter of fact, the experiment 
scarcely differs from the ordinary sensorial reaction experiment, 
because it is customary in the latter to give an occasional false 
stimulus. 

In the “ choice ’’ reaction experiment, the subject has to react 
differently to different stimuli; e.g., he has to react with his 
right hand to blue and with his left to red (simple choice). Or 
he may have to react to ten different stimuli with each of 
his ten fingers respectively (compound choice). Choice-time is 
obtained by subtracting discrimination-time from the times 
obtained in these “ choice ”’ experiments. 

Cognition-time is obtained by subtracting discrimination-time 
from the time taken to cognize a given object, association-time 
by subtracting discrimination-time from the time required for 
the development of an associated idea. The association- 
reaction is of course made with the mouth in naming the 
association; a special mouth-key is accordingly provided for 
this experiment. 

The reaction-times obtained are of little value without corre- 


84 MIND AND ITS DISORDERS 


sponding introspections; but a few are here appended to give 
an idea of the duration of these mental processes: 


Second. 
Cognition (colour) du8 oe Me aol POs 
- (short word) .. a ae .. SO°e5 
Choice (two movements) Ss oe i oe 
,, (ten movements) on ge 1's PROEe 
Association-time .. Ma a ie .. 0°3-0°8 


The more practice a person has in reactions of this nature, the 
more automatic and habitual the reactions are to him, the 
shorter are his reaction-times. In other words, reaction-time 
is shorter for automatic than for volitional action. The above 
times are those of practised observers. 


Unconscious ACTION. 


The manner in which automatic action, as above understood, 
becomes relegated to the subconscious requires no further de- 
scription, but reference must here be made to the phenomenon 
known as “ automatic writing ’’: ‘‘ unconscious writing ’’ would 
be a better term. 

Certain people, usually of a neurotic temperament, are capable 
of acquiring the faculty of allowing the hand to write matter 
of which they are entirely unaware, their attention being engaged 
for the time being in some other way, such as conversation or 
reading a book. At first it is usual for such writing to be a 
nonsensical scrawl, but, with time and practice, it develops into 
a record of previous experiences or elaborate fictions or a com- 
position in verse, even in a foreign language. The subject is 
for the moment split into two personalities with two separate 
and independent activities, a phenomenon which will claim 
further consideration in subsequent chapters. 

Other unconscious actions are the somnambulism of deep 
sleep and the hypnotic state, and the performance during the 
normal state of certain acts which have been suggested to the 
subject while under hypnosis. 

Lastly, there is the state known as absent-mindedness. It 
happens to every one of us at times that we place articles in 
unusual spots, find subsequently that they are lost and, when 
they are discovered, have no recollection of having misplaced 
them. In this way, even valuable documents are sometimes 
thrown away or destroyed and their disappearance remains un- 
explained. Yet, by artificial means of tapping the subconscious 
(crystal-gazing, hypnotism etc.), these absent-minded actions 


UNCONSCIOUS ACTIONS 85 


can often be brought back to memory and phenomenal con- 
sciousness. When an object is mislaid, there is almost invariably 
subsequent amnesia of the act; indeed, this is the main feature. 
Both the action and the memory of it are repressed, a combina- 
tion of psychical activities which suggests that there must be 
some unconscious motive for the mislaying of objects. This 
supposition is confirmed by closer investigation, which reveals 
that the underlying motive is either an unadmitted wish not to 
see or use the article or a secret wish to keep it out of mind lest 
it should remind us of some unpleasing incident. Bills are mis- 
laid more often than cheques, and even valuable presents from 
people we dislike are liable to be lost. 

So with slips of the tongue and pen, and misprints. These are 
usually due to a desire to hurry through a sentence or topic, but 
frequently they betray an unconscious wish of the speaker or 
writer. Punch almost weekly records misprints of interest, and 
his witty comments are often quite sound from a psychological 
point of view. The current number at the moment of writing 
(third edition) contained this gem from a provincial paper: 
“The bride carried a sheaf of harem lilies and orchids’, which 
_Taises the question whether the printer had any knowledge of 
Greek. 

Erroneously carried-out actions come into the same category. 
The giving of wrong change is a familiar example, the error 
being usually in favour of the person who makes it. The sup- 
posedly accidental breakages by domestic servants supply 
another example. The servant would never admit, even to 
herself, that the breakage was intentional; but it gratifies some 
unconscious wish, such as reduction of labour, tending to equalize 
the property of herself and her employer, personal revenge or 
some such kindred unconscious desire. 

Similarly, many apparent accidents of everyday life are 
determined by unconscious motives; for example, taking the 
wrong train, missing the train, unusual arrangement of ornaments 
or articles of furniture without conscious reason, habitually 
applying the wrong key to a lock, and so forth. All such mental 
phenomena prove, on analysis, to be very strong arguments in 


bi 


favour of the doctrine of “‘ psychical determinism ”’. 


Ce Walang etd ve AOL. 
ATTENTION. 


WE are now in a position to understand the nature of attention. 

Altention 1s that process by which the organism is placed in the 
attitude best adapted for the reception of stimuli arising from an 
object attended to or noticed ; whereby the perception of such object 
becomes clearer and more distinct in consciousness. 

The accuracy of this definition will be established as we pro- 
ceed. The attitude of the organism during attention to an 
idea of an object resembles that during attention to a percept of 
the object. 


THE LAWS OF ATTENTION. 


1. The truth of the assertion that attention to a percept or 
idea renders such percept or idea clearer and more distinct is 
well illustrated by the “ puzzle pictures ’’ of cheap periodicals. 
There is perhaps a representation of a landscape and a hunts- 
man and we are told to “‘ Find his dog’’. As soon as we find the 
dog it is so clear and distinct that we cannot look at the picture 
without seeing the dog and it becomes a matter of surprise that 
we did not see it before. At the same time, while we are looking 
at (directing our visual attention to) the dog, we observe that 
the rest of the picture falls into the background, is less distinct 
and less clear. This feature is also noticeable in listening to an 
orchestra. If we single out any particular instrument and 
listen to it, z.e., attend to it, it becomes clearer and more distinct, 
while the rest of the orchestra becomes less clear and less distinct. 
Moreover it is to be noted that there are only these two degrees 
of clearness and distinctness of sensations and percepts, clear 
and not clear, distinct and not distinct; there is no gradation. 
It is true that there are degrees of attention: an object may be 
attended to in such a degree that nothing else is noticed for the 
time being (absorbed attention), as in the historical instance of 
Newton neglecting to dine when working out his system of 
fluxions, or it may be attended to only a little more than other 
processes in consciousness; but in each case there are but two 


degrees of clearness and distinctness. 
86 


LAWS OF ATTENTION 87 


2. Under certain circumstances, it is also to be observed that 
a sensation becomes more intense during attention. This is only 
true, however, when the sensation is of slight intensity. The 
pressure of our clothing passes unnoticed as a rule; but when any 
particular part of the skin is made the object of attention, the 
sensation of pressure there may become so intense as to necessi- 
tate readjustment of the clothing over it. Ifa chord be struck 
- on the piano and allowed to ring off while one of its constituent 
tones is singled out by attention, that tone at once becomes 
louder, more intense. 

3. It has been demonstrated in the laboratory that a sensa- 
tion of extremely brief duration becomes longer when attention 
is directed to it. 

4. A sensation or percept enters consciousness more quickly 
when attention is directed to it. A hammerman sees the sparks 
fly before he sees his hammer strike the iron. If a bell-metro- 
nome be set in motion and attention be directed to the tick, the 
tick is heard before the bell; but if attention be directed to the 
bell, the bell is heard before the tick. 

5. The above experiment also serves to illustrate the pheno- 
_menon known as the inertia of attention. If, by an act of atten- 
tion, the tick be heard before the bell, it continues persistently 
for some considerable time to be heard before the bell, in spite 
of efforts being made to hear the bell before the tick. 

6. Another characteristic of attention is that it fluctuates; 
and it can easily be demonstrated that this fluctuation has a 
regular periodicity. If a watch be placed in the corner of an 
otherwise silent room and listened to from the oppostie corner, 
it is found that the ticking is alternately heard and not heard 
about every four seconds. The same phenomenon may be 
demonstrated in the domain of vision by means of a Masson’s 
disc. A black spot is painted near the periphery of a white disc; 
when this disc is quickly rotated on a colour-top, the black spot 
appears as a very faint grey ring ona white ground. If this grey 
ring be fixated continuously it is found to be alternately seen and 
not seen about every four seconds. Minimal pressure stimuli 
behave in the same way. Lehmann has shown that this pulse 
of attention appears to be dependent upon the respiration. 

7, Experiments have been made with the object of deter- 
mining the number of things to which we can attend at the same 
time. In most of these experiments a number of letters or 
figures are exposed to the gaze for a very short time, say one- 
tenth of a second, and the observer is then required to name 


88 MIND AND ITS DISORDERS 


the letters that he saw. Asa rule the number does not exceed 
five or six. That this does not depend on any normal deficiency 
in the visual apparatus is shown by the fact that at least twice 
this number of letters can enter consciousness if they be arranged 
into words. Under such circumstances several letters combine 
to form one idea. 


THE VARIETIES OF ATTENTION. 


Voluntary Attention. 


By introspection we find that there are many sensations and 
percepts to which we are unable to attend without a certain 
amount of voluntary effort. Attention to sensations of minimal 
intensity, to a lecturer with a bad delivery or to a book on a 
difficult and unfamiliar subject, is accompanied by a distinct 
sense of voluntary effort. 

Now if we endeavour by introspection to discover the con- 
stitution of this sense of effort we find that it is made up of 
numerous sensations of muscular strain. The muscles of the 
eyes and upper part of the face come into play in attention to 
visual percepts or ideas; the head is turned in attention to 
auditory percepts or ideas; there is movement about the lips 
in attention to gustatory sensations; and accompanying these 
movements there is in voluntary attention a sensation of muscular 
strain. If we endeavour by introspection to discover anything 
more than these sensations in the feeling of effort, we fail. The 
conclusion is therefore that this sense of effort (sometimes 
called “‘ conation ’’) consists of nothing more than a number of 
sensations of muscular strain. Further examination of this 
muscular contraction reveals that its purpose is to place the 
organism in the attitude best adapted for the reception of stimuli 
from the object attended to. 

Since these muscular contractions are volitional, we may con- 
clude that they originate in the frontal lobes and that the motor 
impulses are conveyed by way of the pyramidal tract. Mosso 
demonstrated that during an act of attention the respiration 
becomes slower, deeper and more diaphragmatic. 


Instinctive Attention. 


In contradistinction to sensations and percepts attention to 
which is impossible without effort, there are others which im- 
mediately claim our attention. Attention is thus involuntarily 
(instinctively) brought into play by (1) stimuli of great intensity 


INSTINCTIVE ATTENTION 89 


and by (2) stimuli affecting a large area of skin or retina. 
(3) Suddenness of stimulus claims involuntary attention, possibly 
on account of the nervous system having been at rest from 
previous excitation. In this case the stimulus overcomes a 
large amount of synaptic resistance. (4) Movement of an 
object arouses the attention probably for a similar reason, 
fatigue of the sensory tracts being reduced to a minimum. 
(5) Association and (6) contrast of the stimulus with the exist- 
ing contents of consciousness also favour the development of 
involuntary attention. 

Lastly there is the question of ‘‘ interest ’’. Interest in a given 
object depends upon the mental constitution of the individual. 
This in turn depends upon hereditary and acquired mental 
characteristics. Acquired mental characteristics are the result 
of education, not merely the education received at home, at 
school and at college, but also that derived from the individual’s 
conversation with his associates and from his own observation 
of his environment. Hence one individual will have an interest 
in postage-stamps, another in butterflies, a third in the govern- 
ment of his country, a fourth in geology and so forth. Any 
of these individuals will, in one minute’s glance at his morning's 
paper, discover whether there is any information concerning his 
particular hobby. The word “ butterfly ’’ at once catches the 
eye of number two, while the word “ trias’’ attracts number 
four. 

Hereditary mental characteristics are developed as a natural 
result of the struggle for existence in past ages, and these inborn 
tendencies determine what must of necessity be of interest 
to the organism and engage its attention. A sound may be 
the roar of a beast of prey, an object moving across the field 
of vision is a possible meal; and the individual who takes no 
interest in and gives no heed to such stimuli as these pays for 
his inattention with his life. Thus we find that attention, like 
affection, is the inevitable result of the normal processes of 
evolution. 

In each of the above instances, a moment’s consideration 
reveals that the act of attention to a particular percept con- 
sists of a movement, placing the organism in an easy attitude 
for the reception of sensations constituting the percept. 

From the above discussion we may conclude that attention 
of this nature is instinctive in origin and that it must therefore 
be referred to the cortico-rubral system of neurons. 


90 MIND AND ITS DISORDERS 


Reflex Attention. 


It has just been said that suddenness of a stimulus causes 
that stimulus to claim involuntary attention. It is, however, 
almost certain that attention thus aroused is in most instances 
reflex in character and therefore referable to the lowest level of 
the nervous system. When, as I am engaged in writing these 
pages, the whistle in my room is suddenly blown, I experience a 
“start ’’, consisting of a momentary contraction of the muscles 
of my back, shoulders and neck. The muscular sensations 
arising from this start and the sound of the whistle arouse con- 
sciousness at the same time; I do not first hear the whistle and 
then start; the muscular contraction is therefore a reflex action 
referable to my lower motor neurons. Probably many of the 
conditions of instinctive attention mentioned at the top of the 
previous page really belong here. 


We have to recognize that there is a certain amount of inter- 
change between these three varieties of attention. In imme- 
diate succession to the reflex “start ’”’ there is a certain amount 
of instinctive attention to the whistle; then follows an act of 
voluntary attention consisting of rising and listening to the 
message transmitted up the speaking-tube. In listening to a 
lecturer with a bad delivery the sense of voluntary effort dis- 
appears from time to time when the subject becomes interesting ; 
and indeed we find during any lecture that attention becomes ~ 
alternately voluntary and instinctive, and passes through stages 
in which the two varieties are blended. 

It seems fairly clear that there is also an automatie form of 
attention, for experience teaches us that constant efforts of 
voluntary attention create a “habit of attention’ and render 
the action easier of performance. 

In considering the reaction experiment, we found that atten- 
tion to the movement shortened the reaction-time. As was 
stated on p. 8, this is a simple example of facilitation. It 
illustrates the utility of muscular contraction as the essential 
feature of attention; it is the placing of the motor mechanism 
in readiness to act in response to a stimulus. 


Unconscious Attention. 


Attention undoubtedly occurs in dreams, sometimes to such 
an extent as to leave the dreamer tired. It also occurs in the 
somnambulism of sleep and hypnotic states, and it is obvious 


UNCONSCIOUS ATTENTION OI 


that unconscious attention must play some role in the pheno- 
menon of “ automatic writing ’’. 

“Interest ’’ is, of course, a conscious variety of attention; but, 
from what has been said about it, the reader will have correctly 
inferred that it is stimulated by unconscious motives. Indeed, 
it is probable that our ultimate conclusion will be that “ interest ”’ 
is identical with “ instinctive attention ”’ 


To sum up: Attention is a motor reaction placing the organism 
in an attitude whereby a percept attended to rises rapidly, clearly 
and intensively into consciousness, and the organism is placed 
in a state of alertness which may be of vital importance to the 
individual. It is, in fact, nothing more than a special variety 
of action. 


CHAPTER VIII. 
FATIGUE, SLEEP AND DREAMS. 


AFTER action, fatigue! Fatigue may be defined as a diminution 
of muscular or intellectual power, arising from prolonged activity 
of any kind and accompanied by a sense of weariness. Fatigue 
occurs more readily in old age than in youth, in sickness than in 
health, in women than in men, and in some people than in others 
of the same age and sex. Also, we are more fatigued by unusual 
work than by work to which we are accustomed and more readily 
in poor than in robust health. 

Different people become fatigued in different ways. With 
some there is at first an increased capacity for work, this being 
followed by gradually diminishing capacity; with others there is 
no initial increase, but the capacity for work diminishes from 
the first; with a third class the capacity for work remains at a 
high level for some considerable time, then fatigue sets in almost 
suddenly; in yet another class the capacity for work diminishes 
rapidly at first, remains at a moderate level for some consider- 
able time and finally is reduced to mil. These features can be 
reproduced graphically in ergographic tracings made by these 
several people and presently to be described. 

Muscular fatigue is characterized by a certain amount of pain 
in the tired muscles; fatigue in general is characterized by 
quickened pulse and respiration, dilatation of the cutaneous 
arterioles, with perspiration and a consequent fall in the body 
temperature. With some people, perhaps with all, this fall of 
body temperature is preceded by a rise. Yawning is a fairly 
constant feature, as is also a sense of hghtness, heaviness or 
weariness of the legs. The power of attention is diminished, 
ideas tend to become confused and there is weakness of memory. 
There is loss of control of the musculature for fine movements, 
a feature which shows itself in the handwriting. 

Some people when they are tired are subject to palpitation, 
indigestion, dizziness, vertigo, irritability, a sense of heaviness 
or of lightness in the head, tingling and other sensations in 
various parts of the body and hallucinations of vision or even of 

Q2 


MUSCULAR FATIGUE 93 


hearing. These latter symptoms are to be regarded as charac- 
teristic of exhaustion rather than fatigue and should be taken 
as a warning note that the person requires a holiday. 

Muscular Fatigue.—If a muscle-nerve preparation be made 
with the gastrocnemius of a frog and a graphic record be taken 
of some 250 contractions induced, at intervals of a second and a 
half, by electrical stimulation of the nerve, we are enabled to 
study the effects of fatigue on the muscle. We find that con- 
traction and relaxation of the muscle become progressively 
slower, that there is a progressive increase of power during the 
first ten or twelve contractions and that afterwards the muscle 
becomes progressively weaker until at last it cannot be induced 
to contract at all. According to Kronecker, the curve of decline 
in the contractions is a straight line (law of fatigue). 

Left to itself, such an exhausted muscle will recover in the 
course of an hour or so, but if the nozzle of a syringe be inserted 
into the artery of the muscle and the muscle be washed through 
with normal saline solution it will recover immediately. More- 
over, if the washings be injected into a fresh muscle they will 
immediately induce fatigue of that muscle. We learn from this 
_ experiment that the phenomena of fatigue are due to products 
which act as a sort of poison to the muscle. Further, if the 
blood of a dog fatigued by excessive exercise be transfused into 
the vascular system of a fresh dog, the latter at once shows signs 
of fatigue. 

The composition of the products of fatigue, so far as I am 
aware, has not yet been completely determined. All that we 
know is that the chief substances formed when a muscle con- 
tracts are lactic acid and carbon dioxide and Mosso has suggested 
that some leucomaines (alkaloids formed by living tissue) may 
also be produced. At present, however, there is no conclusive 
evidence that any of these substances is wholly responsible for 
the phenomena of fatigue; but we are all familiar with the fact 
that a stuffy atmosphere (carbon dioxide and moisture) is inimical 
to successful work and often induces sleep. | 

In man fatigue has been studied mostly by the aid of an 
instrument called the “ ergograph ’’, devised in its original form 
by Professor Mosso of Turin. It consists of two parts: (1) an 
arm-rest with a pair of bits to hold the hand in position and 
(2) a pulley connected with an apparatus for registering move- 
ments made by one of the fingers to which is attached a string 
supporting, over the pulley, a weight of about 3 pounds. The 
ergograph is a contrivance for recording the curve of fatigue of 


Q4 MIND AND ITS DISORDERS 


different individuals under varying circumstances; this is called 
an “‘ ergographic tracing ’’. 

In making a tracing the finger is flexed as much as possible 
every two seconds, this procedure being continued until the 
flexor muscle is completely fatigued and the finger quite use- 
less. The contractions may be executed either voluntarily by 
the person under observation, or involuntarily by electrical 
stimulation of the motor nerve of the flexor muscle of his finger. 
When the involuntary method is used, the curve obeys the law 
of fatigue; it declines in a straight line. With the voluntary 
method the curve varies with different individuals according to 
the way in which they severally become fatigued (vide supra). 

Maggiora has shown in the following way that the later con- 
tractions are much more exhausting than the earlier, although 
they do much less work. As a rule, two hours’ rest is sufficient 
for all trace of fatigue to disappear from a muscle completely 
exhausted by, say, thirty contractions against the ergograph. 
Now if only fifteen contractions are executed, the muscle is 
completely rested in half an hour; the requisite amount of rest 
is reduced to a quarter when the number of contractions, although 
doing the greater portion of the work, is reduced by one-half. 
Hence Maggiora deduces the “ law of exhaustion ’’, which is that 
‘““ work done by a muscle already fatigued acts on that muscle in 
a more harmful manner than a heavier task performed under 
normal conditions ”’. 

Contracture.—We have seen that, in the case of an involuntary 
ergographic tracing, there is a general increase of the amount of 
work done by the first few contractions. By some this is ascribed 
to the effect of practice, by others it is considered to be the very 
earliest sign of fatigue. In favour of the latter view is the fact 
that, in some excitable and nervous people who are easily sus- 
ceptible to fatigue, the muscle under investigation does not 
completely relax between the contractions, with the result that 
the summit of the curve remains high until fatigue is almost 
complete; and it is a matter of common observation that, when 
a hypermetropic eye becomes fatigued, the patient suffers, not 
from inability to accommodate, but from difficulty in relaxing 
accommodation; in other words, from spasm of the ciliary 
muscle. In the study of intellectual fatigue we shall meet with 
analogous phenomena. 

Intellectual Fatigue.—If an ergographic tracing be taken after 
prolonged mental exertion, it is found that the capacity for 
muscular work is either increased (Rivers) or greatly diminished 


INTELLECTUAL FATIGUE 95 


(Mosso). On closer investigation it is found that tracings taken 
during the earlier stages of mental fatigue show an increase in 
the amount of work done, while those taken during the later 
stages show a diminution. Professor Mosso in his work on 
fatigue gives two ergographic tracings performed involuntarily 
by the finger of Dr. Maggiora before and after examining twelve 
students in hygiene for their degree in the University of Turin. 
The muscular contractions were induced every two seconds by 
electrical stimulation of the median nerve near the axilla. The 
effect of the examinations, which lasted three hours and a half, 
was to reduce the number of contractions from fifty-four to 
twelve, the initial contraction of the second tracing being less 
than three-quarters of the height of that of the first. Similar 
results are obtained by the voluntary method. 

From the latter observations it might be inferred that all 
fatigue is muscular in origin, fatigue-products during mental 
exertion being formed as a result presumably of that muscular 
strain which is a constant concomitant of the act of attention. 
In other words there is no such thing as primary fatigue of the 
nervous system. 

That this is not the case, however, and that the problem is not 
so simple as it appears at first sight, is shown by certain experi- 
ments by Sherrington on the scratch-reflex of a spinal dog. 
There is a large area of skin covering the ribs of a spinal dog, 
mechanical or electrical stimulation of which produces a scratch- 
ing movement of the hind-limb of the same side. Now this 
reflex can be fatigued in a few minutes by persistent stimula- 
tion of a given spot within the said receptive area. That this 
fatigue is of nervous and not of muscular origin is shown by 
the fact that the scratching will start afresh if the stimulation be 
transferred to another spot a few centimetres away, but within 
the same receptive area. This demonstrates further that, so 
far as the nervous system is concerned, the receptive synapse 
tends to become fatigued more readily than the efferent (motor) 
synapse. Sherrington also points out that nervous fatigue passes 
off much more rapidly than muscular fatigue, the scratch-reflex 
being as brisk as ever again after the lapse of a few minutes. 

The following method of obtaining a direct curve of intellectual 
fatigue in man has been devised by Weygandt. The necessary 
apparatus consists of a clock which rings a bell once a minute 
(or other prearranged time), a sheet of numerical figures arranged 
in vertical and horizontal lines, and a pencil. The clock is set 
going and the person under observation takes the pencil. When 


96 MIND AND ITS DISORDERS 


the bell rings he starts adding up to the first vertical column as 
quickly as he can. When the bell rings again he ceases adding 
up the first column, draws a line, writes down the result so far 
as he has gone and immediately starts on the second column. 
The same process is repeated, and when the bell rings a third time 
he passes on to the third column, and so on. The experiment 
is complete when about twenty columns have been added. On 
examination of the resulting curve it is found that the added 
portions of the columns at first increase in length; then, as the 
secondary effect of fatigue sets in, the length of the added portions 
gradually diminishes. Mistakes also occur more frequently in 
the later columns. 

The study of fatigue is yet in its infancy, but we are justified 
in asserting that all its phenomena are due to the formation 
of paralyzing products within the muscular, and perhaps the 
nervous, system; and it need be no matter for surprise that the 
initial action of these products is stimulating in its nature, when 
we reflect that the same is true of many of the sedative drugs 
we possess, ¢.g., chloroform, ether, morphia, cannabis indica 
and alcohol. 


SLEEP. 


And after fatigue, rest! Sleep is the condition of partial or 
complete unconsciousness which normally recurs once in twenty- 
four hours and occupies about one-third of that time. 

Sleep abolishes fatigue; in other words, it helps to rid the 
organism of fatigue-products. In what way it does so, whether 
by destruction or excretion, 1s unknown. 

Sleep varies in its soundness or depth. By awakening sleepers 
with the noise of brass balls falling from various heights on an 
open board, it has been shown that sleep is deepest about an 
hour and a quarter after its onset and that its depth may be 
represented by a curve as shown in Fig. 20. 

All the vital functions are reduced during sleep; the pulse and 
respiration, which is mainly diaphragmatic, are slowed and the 
excretion of urine and of carbon dioxide is diminished. Heat- 
production is at its lowest; we therefore require to be more 
warmly covered than during waking hours. The heat-produc- 
tion during sleep is roughly 4o kilo-calories per hour as against 
roo during rest, 150 during moderate movement and 300 during 
exercise. The brain is partially anemic during sleep as is 
evidenced by the depression over the anterior fontanelle of 
infants and over trephine holes in adults and by certain experi- 


SLEEP 97 


mental observations on lower animals. The optic disc is pale, 
the retinal arteries small and veins large. The voluntary muscles 
are relaxed and the superficial and tendon reflexes absent. The 
muscular tone of the flexors of the fingers is perhaps increased, 
that of the orbicularis palpebrarum is undoubtedly increased 
while the levator palpebre superioris is relaxed. If the eyelids 
be raised it will be seen that the eyeballs are rotated upwards and 
that. they have a constant slow lateral movement, the two globes 
moving independently of one another. The pupils are contracted. 

The tendency of young infants and of the insane to fall out of 
bed is a curious illustration of the general principles of evolution 
and dissolution. 


25 


5 ome 
0 
mei cee oF 4) 6G GT 


Fic, 20.—SLEEP CHART (AFTER E, W. SCRIPTURE). 


Horizontal scale gives hours after falling asleep. Vertical scale gives 
energy of falling ball in thousandths of gramme-centimetres (weight 
of ball x height of fall). Although it cannot be said that the intensity 
of the sound was proportional to the energy of the falling ball,yet the 
scale can serve as a fair approximation to a scale of sound-intensities. 


It would appear that it is possible for isolated portions of the 
mind to remain awake while the remainder sleeps. According 
to Professor James, a mother sleeping soundly by her sick child, 
in spite of the noise of traffic and of people talking in the room, 
awakens to full consciousness at the feeblest cry of her sleeping 
babe. 

The act of going to sleep is normally an auto-suggestion. We 
place ourselves in a comfortable position, adjust our eyes etc. 
to the attitude of sleep, think of going to sleep and in a few 
minutes ‘sleep results. If a person retires to bed thinking that 
he will not sleep, the result is that he lies awake for hours. 
According to Professor Baldwin self-consciousness is inimical 

fi 


98 MIND AND ITS DISORDERS 


to sleep; the idea that J am going to sleep is not so soporific as 
the idea that someone else is going to sleep. 

The condition of the neurons during sleep is of great interest. 
It has been found that excessive activity causes disappearance, 
at least to a considerable extent, of the chromatoplasm from 
nerve-cells and that rest allows it to reaccumulate. It has also 
been demonstrated experimentally that the gemmules are pro- 
truded during sleep and retracted during activity (Lugaro). It 
may therefore be assumed that, during the process of going to 
sleep, the gemmules are gradually being protruded. It is con- 
ceivable that during this stage a new interneuronic (synaptic) 
association occasionally occurs for the first time. Now in con- 
sidering automatic action we saw reason for the belief that the 
occurrence of new or unusual synaptic connections between the 
neurons induced instinctive or reflex attention; and we have 
further seen that an ordinary “start ’’ is nothing but a special 
form of reflex attention. We thus see a possible explanation of 
the “start ’’ which, during the process of going to sleep, occurs 
so frequently during the first half of life. When once the neurons 
are all connected up, attention to external environment is no 
longer possible and all slight sensations pass unnoticed. 

There can be no psychology of deep dreamless sleep. When a 
person is unconscious, all mental operations are in abeyance: 
what more can be said? In very light sleep, however, when we 
are not quite fully awake, there is a marked tendency to the 
formation of hallucinations, especially visual. This condition 
is known as the hypnagogic state, and the hallucinations as 
hypnagogic hallucinations. Coriat reports the occurrence of 
catalepsy and what he calls “ nocturnal paralysis ’’ in this state. 

As a result of such observations various theories of sleep have 
been formulated, all of which contain an element of truth. 
These are (1) that it is caused by cerebral anemia; (2) that it is 
due to a general linking up of neurons, so that synaptic resistance 
is reduced to a minimum; (3) that it is induced by intoxication 
of the nervous system by the products of fatigue; (4) that it is 
to be ascribed to lack of oxygen and excess of carbonic acid 
in the brain; (5) that it is owing to the absence of distracting 
external stimuli; (6) that it is an instinctive reaction of defence 
of the organism against fatigue, evolved by processes of natural 
selection. (1) and (2) should probably not be regarded as causes, 
but rather as effects or concomitant features; while experience 
in the fighting-line during the War has proved (5) to be an un- 
essential factor. Our conclusion is, therefore, that sleep is the 


DREAM DISTORTION | 99 


result of an instinct to place ourselves in conditions favourable 
to its production. Chief among these is a situation or attitude 
depriving the organism of oxygen or supplying it with an excess 
of carbon dioxide. Birds tuck their heads under their wings, 
rabbits seek their stuffy burrows, other animals curl up and bury 
their noses in soft parts of the abdomen and man buries his 
face in the bedclothes. Fatigue, which is partly due to the 
accumulation of carbon dioxide in the tissues, may render such 
attitudes unnecessary, and it seems clear that (3) and (4) are 
really the same thing. In support of the view that sleep is an 
instinct there is plenty of psycho-analytic evidence to show that 
a sleeper wishes during sleep to continue sleeping. 

Dreams.—During sleep, but probably not during deep sleep, 
most people are subject to dreams. A few people never have a 
dream in their lives. Dream-perceptions are mostly visual; next 
in order of frequency come auditory perceptions. Visual dream- 
perceptions are usually coloured, but it is noteworthy that un- 
saturated colours and intermediate shades of colour are unusual 
in dreams. Olfactory hallucinations are also extremely un- 
common in dreams, and gustatory sensations practically never 
occur. If we dream we are at dinner, we see the various dishes 
but very rarely eat anything; and if we do, we find invariably 
that the dainty is entirely devoid of taste. When dream-smells 
occur it appears to be the rule for them to persist for a short 
time after waking. 

Dream-movements also have their characteristics. Apart 
from flying and floating sensations in which the body moves as 
a whole, movements at the small peripheral joints are easy of 
performance, while movements at the large proximal joints are 
difficult. I do not refer to actual (somnambulistic) movements 
performed during sleep. We can waltz or spring and we can 
write or sew with ease; but if we attempt to strike or kick an 
adversary, we can get no force into the blow: it is like trying to 
kick him when we are immersed in water. It was suggested by 
Dr. Hughlings Jackson that this is due to a larger representation 
in the frontal lobes of peripheral than of proximal movements. 
The psycho-analytical interpretation of the phenomenon would 
be that there is an absence of any unconscious wish to get force 
into the blow, which may or may not symbolize some other form 
of activity. 

In past ages, and even to-day among ignorant and unprincipled 
charlatans, dreams have served as a basis for prophecy, necro- 
mancy, telepathy and even religion; but the researches of Freud 


100 MIND AND ITS DISORDERS 


and many of his followers have completely robbed dreams of their 
mystery. It is now definitely established that they are nothing 
more than the imagined fulfilment of unconscious or, less com- 
monly, conscious wishes, memories of our experiences during 
waking hours being utilized in the process. 

Various elements of the dream are doubtless distorted out of 
all recognition, so much so, indeed, that events in the dream 
frequently seem to be the very opposite of what they really 
represent. Such distortion varies in different individuals; but 
we may state generally that it is much greater when the wish 
fulfilled is unacceptable to waking consciousness, the alert 
mind unwilling to admit the desire, and, in fact, the wish has 
been repressed into the unconscious. Sexual desires are the most 
repressed of all, and therefore they are the most disguised. 
Indeed, few people unfamiliar with psycho-analysis would admit 
that their dreams have any sexual meaning whatever; but, as a 
matter of fact, psycho-analytical investigation, to be discussed in 
a subsequent chapter, teaches us that there is a sexual element 
in nearly every dream. 

We have, then, to recognize that there is a manifest and a 
latent content of every dream. The manifest content includes 
the incidents of the dream as they might be related at the break- 
fast-table next morning; the latent content is the deeper meaning 
which is ascertained by studying the mental associations of 
various items of the dream, and this always turns out to be a 
wish fulfilled. This is the real object and purpose of dreaming, 
to gratify unconscious desires which can obtain gratification in 
no other way without producing mental disorder, while the dis- 
tortion of the dream serves as the guardian of sleep. When the 
deeper meaning, the latent content, of a dream is insufficiently 
disguised, the dreamer awakes. 

The chief mechanisms of the distortion are four, viz., Displace- 
ment, Condensation, Symbolization and Dramatization. 

Displacement.—The dream substitutes one person for another 
or one idea for another. For example, a passing friend of years 
ago who has passed out of one’s life always stands for somebody 
of intimate biological importance to the dreamer. Moreover, 
apparently unimportant items of a dream are commonly the most 
significant, as also are vague details, perhaps forgotten at first, 
but subsequently remembered, or remembered at first, but 
subsequently forgotten. 

Condensation.—Most elements in a dream comprise many 
unconscious thoughts. For example, a patient of mine dreamt 


HYPNOTISM Io! 


that she was in Ashley Road in a provincial town in which her 
mother-in-law lived. Ash referred to Dr. Ash, who had treated 
her by hypnotism—“ley”’ referred to the River Lee, on whose 
banks she contemplated building a house, and also to Leigh 
Denny, a character in a novel she had read, who stood for her 
husband. Unrecognizable people are usually condensations of 
two or more persons—the eyes of one, the clothes of another, 
some characteristic pose of a third, and so forth. 

Symbolization.—Even in everyday life symbolism is in common 
use. “A bed of roses’ symbolizes freedom from care, “‘ thorns ”’ 
symbolize trouble, “red tape’”’ symbolizes officialism and the 
national flag the nation. Such symbolism is utilized much more 
freely in dreams. Walking with a person means agreement with 
him or payment of homage to him (“‘ Enoch walked with God’’). 
Hollow objects (houses, boxes etc.) symbolize the female body. 
Long objects (sticks, swords, pistols, syringes etc.) symbolize 
the male genital organ, as also do musical iustruments. Emperor 
and Empress, King and Queen, stand for father and mother, and 
so forth. Symbolization is a subject which might well claim a 
chapter for itself, or even a book; but it is better for the student 
_ to discover symbolisms by experience. 

Dramatization-The dream is presented in a more or less 
dramatic form by introducing and arranging people, objects and 
situations in such a way that they will fit into the picture. For 
the same reason past and future both become the present. 

In conclusion of this brief epitome of dream psychology, let 
me repeat that the latent content of a dream is always the fulfil- 
ment of a conscious or, more commonly, an unconscious wish. 
A dream is not interpreted until this wish is discovered. 

Hypnosis.—In the special form of sleep known as hypnosis the 
subject has a vivid idea that he is going to sleep under the 
operator’s influence, and it is the duty of the operator to en- 
courage this idea by means of “ passes’, incantations, stroking 
the skin etc. If the subject has an idea that the operator cannot 
send him to sleep, the latter will undoubtedly fail. It is clear 
therefore that hypnosis is in reality an auto-suggestion just as 
ordinary sleep is. 

There are roughly three stages or degrees of hypnosis which 
merge into one another. The first is that of “ flexibilitas cerea ”’, 
in which the limbs are rigid but may easily be moulded into 
any attitude by the operator. In this stage there is anesthesia 
of certain portions of the skin and the subject is extremely sus- 
ceptible to suggestion. In the second stage, that of “‘ lethargy ”’, 


I02 MIND AND ITS DISORDERS 


the whole body is flaccid and the subject appears to be entirely 
unconscious. The third stage is that of ““somnambulism’”’, in 
which the subject is again extremely susceptible to suggestion 
and there is exaltation of the senses with disturbance of memory. 
In this stage mere suggestion from the operator suffices to enable 
the subject to perform actions which are impossible to him during 
his waking state. On awakening he has no memory of these 
actions; yet, on the other hand, suggestions, given during 
hypnosis, of actions to be performed subsequently at a given 
time when he is awake, are satisfactorily carried out without 
his being able to give any reason for such actions. Moreover, 
the hypnotized subject is able to remember incidents which he is 
unable to recall in his normal state. By hypnotism, therefore, 
we are able to broach the unconscious in order to discover hidden 
memories and to influence subsequent conduct of a patient. 
Indeed the very lowest levels of the nervous system may be 
affected by this means; certain hypnotists have succeeded, for 
example, in raising a blister on a subject by applying a piece of 
stamp paper and suggesting that it is a piece of charta 
epispastica. 

Not that the lowest level of the nervous system is immune 
from psychical influence in the normal state, for the so-called 
““ MENTAL REFLEXES ”’ prove the contrary. As Pawlow has demon- 
strated, a dog secretes limpid saliva if you show him a biscuit, 
but viscid saliva if you show him a bowl of porridge. The 
nipples of a woman become erect if she thinks of suckling her 
child and sexual thoughts produce specific vaso-dilatation. If, 
in a dim light, you think of looking into a dark cellar, the pupils 
dilate and if, without moving, you then think of looking at 
the setting sun, the pupils contract. Again, let a person fixate 
a spot on the wall while the light of a lamp falls on his eyes 
from the periphery of his visual field and note the size of his 
pupils; then tell him to direct his attention to the light without 
moving his eyes, and his pupils will contract. Other examples 
might be cited, but these will suffice to confirm the important 
fact that the highest functions of the nervous system may actuate 
the reflexes of the lowest level. 

Several sittings are requisite in most cases before a person can 
be satisfactorily hypnotized; but when once hypnotism has been 
induced it is an easy matter to hypnotize him on subsequent 
occasions. For this reason an operator should always “‘lock’”’ ~ 
his cases by the suggestion that the subject cannot be hypnotized 
by anyone else, lest he get into the hands of some unscrupulous 


HYPNOTISM I03 


person. A hypnotized subject, if left to himself without any 
suggestion, falls into a natural sleep and then wakes up. 

The phenomena of hypnosis, wonderful as they are, do not 
merit the shroud of mystery in which they have been enveloped. 
I believe they could all be found at times in ordinary sleep. 
In both conditions the attention is purely instinctive and lacks 
the “inertia ’’ of waking attention; and there is much the same 
disturbance of memory in both. Somnambulism occurs in deep 
hypnosis, just as it occurs in deep sleep about an hour after 
retiring to bed. And with regard to the suggestion business, 
we are all as susceptible to suggestion as we can well be during 
our waking moments; the ordinary somnambulist is only more 
so. When told to retire from a dangerous position and to return 
to bed, he does so immediately. Whether he would perform such 
tricks as are done by the victims of professional hypnotists, if 
they were suggested to him, I am unable to say; probably he 
would. 

It must be admitted that, for successful hypnosis, the patient 
must have confidence in the hypnotist; and Ferenczi has shown 
that this state of confident rapport is not unattended by feelings 
_of a more positive kind, such as affection, friendship and even 
love. This explains why patients treated by hypnotism are 
liable to develop undue dependence on their physician. 


DEAR Ten 
THE SENTIMENTS. 


THE sentiments are somewhat allied to the emotions. An 
emotion is a sensation-complex resulting from an involuntary 
reaction to a percept or idea; a sentiment is a sensation-complex 
which arises when judgment is passed on the way in which 
a percept or idea affects the feelings. In the former case atten- 
tion to the percept or idea is instinctive; in the latter it is volun- 
tary. Emotion is a less conscious process than sentiment. 

There are three kinds of sentiment: the esthetic, the moral 
and the intellectual. The esthetic sentiment arises in associa- 
tion with the passing of a judgment upon a thing, sometimes 
upon an action, the moral when judgment is passed on an 
action; and the intellectual when judgment is passed on a 
judgment. 

The esthetic sentiments form the largest group. The judg- 
ments formed in association with these answer the question: 
Is this beautiful or ugly? They include the sentiments of 
beauty, ugliness, comedy and tragedy. A thorough investiga- 
tion of the first two of these would comprise a study of all the 
laws relating to art. It would include a study of symmetry, 
asymmetry and curves; of the combination and contrasting of 
colours; of the movements of dancing; of the most pleasing 
combinations of tones in music, of the formation of melodies 
and other sequences (avoiding consecutive fifths and octaves), 
of fugue, counterpoint and orchestration. Moreover, we would 
have to investigate those unorthodox forms of art which break 
recognized rules and forms in order to give enhanced pleasure. 
Indeed, a psychological study of the reasons why modern artists 
and musical composers have regressed to the primitive (cubism, 
futurism, negro music, studied discord without attempt at sub- 
sequent resolution etc.) would prove a most interesting chapter. 
Finally we would have to analyze the biological reasons why 
certain of these forms give greater or less pleasure than others; 
but all this, despite its importance, would obviously be outside 


the province of this manual. 
104 


THE SENTIMENTS 105 


The study of comedy and tragedy is perhaps more important. 
Tragedy as such has received but little attention from psycho- 
logists, although many of the characters in tragedy have been 
analyzed very thoroughly. On the other hand, volumes have 
been written about comedy and the comic. By comedy we mean 
a combination of the beautiful with the ludicrous, by tragedy a 
combination of the beautiful with the sad. This meaning of 
_ comedy and tragedy differs somewhat from the popular notion 
of these sentiments. We read on the evening placards of a 
“ tragic’? murder in Whitechapel when the paper contains an 
account of some loathsome incident totally devoid of any of the 
beautiful touches of true tragedy. Possibly such an incident 
arouses in a morbid individual some sentiment analogous to that 
of true tragedy as experienced by a man of finer feelings when 
he reads Shakespeare’s ‘‘ Romeo and Juliet’. Similarly common 
folk regard coarse and disgusting stories, devoid of wit, as comic 
when there is no trace in them of the beautiful touches of true 
comedy. By the way, the underlying reason why these may 
give rise to hilarity is that they are symbolized sexual aggressions 
against the person to whom they are related. 

The essence of comedy is sudden incongruity. If you see a 
child wearing his father’s hat, there is something absurdly 
ludicrous in the picture; but if you expect to see him in it and 
have already formed some idea of how he would look, most of 
the comedy of the situation disappears. The first time you hear 
of the famous general who pounced out of his front door upon 
a lady visitor in response to what he believed to be a runaway 
knock the comedy of the situation is much more striking than 
when the story is repeated, although we still appreciate the 
incongruity. The reason why we feel bored by so-called “ chest- 
nuts’ is that their incongruity lacks the suddenness which is 
necessary to mirth. 

Premeditated comicalities of speech, such as are produced by 
a play on words, puns, nonsensical remarks, double meanings, 
ambiguities and a host of other factors, are known as “ wit ”’; 
and Freud has shown in a masterly work that all wit is of un- 
conscious origin and that the underlying mechanisms are to a 
large extent identical with those of dreams. 

Laughter, which is regarded as the expression of the emotion 
corresponding to the sentiment “‘ comedy’, is somewhat of a 
puzzle to psychologists. It appears to be evolved from the 
smile which makes its appearance in the infant before the laugh; 
and the elementary form of both is supposed to be the reaction 


To6 MIND AND ITS DISORDERS 


to tickling. Tickling, in turn, is regarded as playing at attack. 
Laughter is therefore an expression intimately associated with 
play. It is not perfectly clear what is the teleological value of 
laughter, but the following has been suggested : 

The essence of children’s play is make-believe, pretending to 
do that which in after-life they will be called upon to do in 
reality. In other words play is the instinctive exercising of 
muscles in preparation for the work of real life. And when in 
play a puppy flies at its mother’s throat or a human infant 
beats its mother, smiling or laughter on the part of the mother 
will indicate to the offspring that it has not gone too far. A 
change in the mother’s expression will then indicate danger and 
cause the offspring to cease striking her. 

Other psychologists think that we laugh to avoid being miser 
able, that laughter is an antidote to melancholy or to sympathy. 
A little consideration shows that there is a good deal to be said 
for such views. Why is it that some people laugh till they cry ? 
Why does the sight of a man chasing his hat over the mud on 
a windy day provoke laughter ? Why does a child laugh when 
tickled and struggle to escape at the same time ? 

The moral sentiments include the social, the ethical and the 
religious. The judgments formed in association with these 
sentiments answer the questions: “Is this antisocial?” “Is 
this good or bad for the individual or for the race ?”’ “ Is this in 
accordance with the Divine Will?’’ The common characteristic 
of actions which are judged as moral is that they involve the 
foregoing of present pleasure for the purpose of enhanced benefit 
or diminished inconvenience in the future to the individual or the 
race. Immorality arises from deficient voluntary control of the 
baser instincts. Fundamentally morality is a tendency to comply 
with the wishes of one’s fellows; but what those wishes are has 
to be taught to and learned anew by every individual during 
his childhood. In due course this acquires the force of an instinct, 
which Freud has called the ego-instinct. I hope that this digres- 
sion will not cause the reader to confuse the moral sentiments 
with the ego-nstinets. 

The judgments formed in connection with the intellectual 
sentiments answer the question: “‘Is this proposition true or 
false ?’’ ‘“‘ Am I to believe it or not ?”’ 

Belief.—Every judgment implies the possibility of an alterna- 
tive: the judgment “ This is so’”’ implies the possibility of the 
judgment “ That is not so”’ and it is left to the individual to 
accept one or other of these. Belief in the latter implies dis- 


BELIEFS 107 


belief in the former. Belief and disbelief are therefore the 
same mental process. Their common antagonist is doubt, which 
is an oscillation between belief and disbelief and gives its charac- 
teristic emotional tone in sensations derived from muscular 
tension and restlessness. The emotional tone or belief or dis- 
belief is that of relief, dependent upon relaxation of the muscular 
tension associated with doubt. 

Under ordinary circumstances a judgment is believed when it 
does not contradict any other judgment which we have formed; 
it then arouses the emotion of conviction, which 7s belief. The 
final court of appeal is that of the organs of special sense. If 
we can see a thing we perceive it as a reality and believe it. Yet 
who is to say what is real and what is imaginary in view of the 
cases of double consciousness or of those of hallucinations of 
vision ? These latter are so real to the patient that he throws 
his boots at the objects he sees. And what becomes of reality 
when a sleeper dreams “‘ This is no dream; this is reality ’’ ? 

There are three forms of belief, which may be termed respec- 
tively (1) rational belief, (2) intuitive belief and (3) belief by 
suggestion. In the first form, rational belief, the individual 
examines the evidence for and against a given judgment, wherever 
possible referring each piece of evidence, as it arises, to his 
organs of special sense. When, by such a process of reason- 
ing, a person arrives at a conclusion, his belief may be termed 
“rational ’’. 

It is quite possible for a person to have a rational belief in 
an erroneous judgment, some fallacies having crept into his 
train of reasoning; but this does not affect the psychical nature 
of his belief. The late eminent neurologist, Dr. Charlton Bastian, 
believed that the spontaneous generation of living organisms 
goes on at the present day. Most, if not all, other scientific 
men believe Dr. Bastian’s judgment to be erroneous in this 
matter; but he arrived at his conclusions by processes of experi- 
ment and reasoning. His belief in them was therefore rational. 

In other cases a person believes in a given judgment without 
going through any such process as the above. He or, more 
commonly, she feels that such and such is the case and, merely 
on account of the feeling, believes it to be so. One of the most 
common examples of this form of belief occurs when “ the wish 
is father to the thought ’’. A woman, with a distant relation 
whom she loves, may suddenly become convinced that evil has 
befallen her dear one; and she believes it. Such beliefs as 
these have their basis in the unconscious which induces some 


To8 MIND AND ITS DISORDERS 


emotional tone of feeling. For this reason, they may be called 
“instinctive or intuitive beliefs”. They are by no means 
always erroneous; but their nature is such that they must be 
banished from most scientific thought. Intuitive belief is, how- 
ever, frequently useful in psycho-analytical investigation. The 
subject feels that there is a connection in his mind between one 
idea and another, although for the moment the nature of the 
connection cannot be discerned; yet, as the analysis proceeds, 
the nature of the connection is ultimately discovered and the 
original intuition justified. 

“ Belief by suggestion’ is unquestioning belief in a given 
statement made to the individual. When someone tells me 
that Mrs. Jones died last night, offhand I believe it although 
Mrs. Jones appeared to me last evening to be in the best of 
health. Superstitious beliefs are usually of this nature; others 
are symbolic of a deeply hidden unconscious wish common to the 
whole human race. In one form of practical joking, “ pulling 
a person’s leg ’’, commonly practised on April I in each year, 
advantage is taken of this tendency to “ believe by suggestion ”’. 


, 


(elie Eee Ns, 
LANGUAGE, 


In studying the emotions we concluded that their expression 
was their very essence; a careful observer can tell another 
person’s feelings by noting his expression. It does not always 
require careful observation; when a fox flies from his hunters 
he expresses terror in an unmistakable manner. The contention 
of those who encourage this form of “ sport ’’, that the fox enjoys 
it, is absurd; the fox is telling them the whole time in his own 
language that he is terrified. 

The above might be called an example of instinctive language. 
It is the language of “ gesture”. But let us examine some 
forms of intellectual language in which an animal voluntarily 
expresses his thoughts. When a dog sees you eating a biscuit 
and sits up on his haunches, he is telling you that he would like 
a piece of it; when a foreigner, unfamiliar with the English 
tongue, walks into a restaurant and points to his mouth, he is 
asking for food in the same language as the dog; and when a 
man beckons, he is saying in the same language “‘ Come here ”’ 
Such language has been called “‘ pantomime ”’. 

A much more convenient form of language is one in which 
sound plays an important part, because it serves to attract 
another’s attention when he is not looking your way. Many 
animals have a very limited sound language, generally of the 
instinctive variety ; for example, a sheep has two such words, viz., 
‘“Baa’’ meaning (perhaps) “I am in distress’’ and “‘ Swish ”’ 
meaning “‘ Look out! there’s someone coming ’’. Ants are in- 
capable of making much sound and I think I have read some- 
where that they are deaf; accordingly they have to convey their 
ideas to one another in a tactile language, by means of their 
antenne. 

Man has the advantage of all these animals in having a lan- 
guage of words. The advantage lies in the fact that words 
can be expressed by means of sound (spoken language) or light 


(written language) or even by the sense of touch (language of 
109 


IIO MIND AND ITS DISORDERS 


those who are both blind and deaf). Words are the symbols 
of our mentation and are to be regarded as psychical things 
whose physical basis is situated in the motor centre for speech 
in the third left frontal convolution of the brain.* It is there 
that the ideational centre for the action of speech is situated; 
it is there that word and sentence motor-ideas arise. But we 
have already seen that our idea of any object, for example a 
violin, may be visual or auditory as well as motor; and the 
same is the case with words. We may have a visual idea of a 
word as it is written or printed or we may have an auditory idea 
of the word as it sounds when spoken. 

We know that the visual idea of a word is formed (in right- 
handed people) in the neighbourhood of the left angular gyrus. 
If the left angular gyrus of a right-handed man be damaged 
he can see a printed word as well as any of us, but the word has 
for him no ideational content; it might as well be Chinese. 
Such a patient is said to be suffering from word-blindness. 
Word-vision is only a special department of visual perception 
and the word-vision centre behind the left angular gyrus is only 
a part of the area for visual-perception in general. The right 
occipital lobe participates with the left in the perception of 
objects other than words. 

Similarly the word-hearing centre is a part of the centre for 
auditory perception in general and is situated in the first temporo- 
sphenoidal convolution. The corresponding convolution on the 
right side participates with it in the perception of sounds other 
_ than words and perhaps of music. The physical basis of per- 
ception of such sounds as that of a soda-water siphon in action 
or of paper being torn lies in the first temporo-sphenoidal con- 
volution of both cerebral hemispheres. 

Lastly there is a motor centre for written language, situated 
in the neighbourhood of the “ hand-area’’, anterior to the left 
fissure of Rolando. Patients unable to write, on account of 
a lesion of the writing centre, are said to be suffering from 
“agraphia’’. Loss of the motor-idea of writing is difficult to 
determine in these patients because of their physical disability 
(paralysis of the right arm and hand). 


* Marie threw some doubt on the existence of an ideomotor centre for 
speech. He believed motor aphasia to be nothing more than anarthria 
(defective articulation) plus acquired defect of intelligence. Apart from 
the fact that the existence of such a centre brings speech into line with 
other movements, aphasia being nothing more than a special form of 
apraxia, Marie’s hypothesis does not account for the clear enunciation of 
“ recurring utterances ’’ by aphasic patients. 


SPEECH Diy ia 


Speech, then, is a psychical thing consisting of word-ideas 
which are our symbols for other ideas. I wish particularly to 
emphasize this point, because there appears to be a tendency 
to confuse speech with articulation, which belongs to a lower 
order of things altogether. Occasionally we hear it said that 
a person’s “‘speech’’ is tremulous, when it is meant that his 
“articulation ’’ is tremulous. The distinction is not merely 
~ academic; the student who confounds articulation with speech 
must of necessity confuse their physical bases. The physical 
basis of speech is, as we have seen, in the ideational (association) 
centres; the physical basis of articulation is in the cortical 
projection areas and in the hypoglossal nucleus. In the exercise 
of our profession we are largely dependent on the word-symbols 
of our patients in our endeavours to arrive at a correct diag- 
nosis; but if we confuse the physical (articulation) with the 
psychical (speech), we make a false start and lay a foundation 
for erronecus diagnosis. 


LANGUAGE AND THE UNCONSCIOUS. 


‘ 


Reference has already been made to “ automatic writing ’’, 
which is the best recognized variety of unconscious language; 
and it has been mentioned at the end of the chapter on Action 
that slips of the tongue and pen are the expression of unconscious 
wishes. 

I will here content myself with a personal example of a slip 
of the pen. I was asked to open a discussion on psycho-analysis 
before an audience which would probably be very antagonistic. 
After much hesitation, I finally consented by letter, should my 
correspondent “ get up the debate’’; but in my reply a slip of 
the pen occurred and I wrote “ give’’ instead of “ get ’’, thus 
betraying the unconscious wish. Of course I had to rewrite the 
letter. 


CHAPTER XI. 
THE EGO, 


As conscious individuals each of us recognizes that there is in 
him something he calls “I” or, psychologically, his “ Ego ” 
Each one of us draws a distinction between “ self’’ and “ not- 
self’’, ““me’’ and “ not-me’’, the consciously thinking subject 
which perceives, experiences pleasure and pain, seeks information 
and strives for ideals, as opposed to the objects perceived, the 
pleasure and pain experienced, the information which is sought 
and the ideals which are pursued. 

Of what does this ego consist ? Many psychologists have made 
rather a mystery of the conception. Some speak of an ego- 
complex as if to imply that the ego feeling is unconscious. To 
be sure, the concept of one’s own personality is not always 
present in the conscious, but it can easily be raised piecemeal 
into consciousness. It is therefore to be regarded as persistently 
preconscious, for the whole content of the ego can never be in 
full consciousness at the same moment. At any rate, it is not 
unconscious, and it is therefore wrong to speak of it as a complex. 

Let us attempt to trace this ego-sense from its very beginning. 
The child asleep in its mother’s womb certainly has no sense 
of its own personality; but the frightful experience of being born 
and the intense terror inspired thereby must of necessity give 
the child some initial sense of its own individuality. After the 
birth is all over, the baby constantly tends to return to its primi- 
tive state of sleep. This is only interrupted by feelings of un- 
satisfied desire, the want of food, the desire to evacuate the 
bowels or to pass urine or, in certain circumstances, the wish for 
relief from partial suffocation or from stimulation of the respira- 
tory tract in some other way. It would therefore appear that 
the ego-sense is engendered, at any rate in the first instance, by 
a feeling of dissatisfaction or discontent, otherwise by desire,* 
wishes, aspirations and all that these connote—enterprise, 
venture, striving and activity. 

Let us here digress for a moment to combat the notion that 

* I do not say ungratified desire because desire ceases aS soon as it is 


gratified. 
112 


MAN AND WOMAN ned ES 


our material body plays an important part in our concept of self. 
It is true that the self idea is primarily dependent on physical 
sensation, as are all other ideas and concepts; but nobody at any 
time uses the word “I ”’ in the sense of “‘ my physical body ”’. 
It never occurs to us that we leave part of our ego at the hair- 
dresser’s, at the dentist’s or at the surgeon’s. Moreover, a child 
will offer its toe a biscuit and a dog will run after its own tail. 

From the four vegetative wishes above mentioned (stimulation 
of the mouth, the anus, the neck of the bladder and the respiratory 
tract), that which at first sight would appear to bring the child 
into relationship with the external world is the first: sucking the 
mother’s breast; yet the new-born child knows nothing of its 
mother. Placed into sufficient contiguity to the breast a perfectly 
healthy new-born infant will seek the nipple and suck it. Itis 
usually quite unnecessary for the mother to place it in the baby’s 
mouth. The baby accepts the mother’s breast as part of itself and, 
on further consideration of the matter, we find that what the 
child considers as not-self is anything or anybody that opposes the 
gratification of its wishes. So far, therefore, our definition of the 
ego would be “ that which experiences desire and gratifies it ”’. 

As life advances our wishes become more numerous and more 
complicated. Excluding the wish to avoid things, the “ desire 
of aversion ’”’, our desires are mainly those of possession and of 
achievement. Those possessions which are most closely bound 
up with the ego are those which are in closest relationship with 
the person, such as our clothes and things, for which we have 
striven and obtained by our own efforts. And as to our achieve- 
ments, these are what maintain a sense of self-esteem (Narcism), 
while adverse criticism of our work is a severe blow to our ego- 
sense, to our Narcism. 

The ego, then, is very dear to each one of us. When a man 
says “I would like to be Lord Leverhulme ’’, he only means 
that he would like to be possessed of that man’s wealth and 
capabilities. He does not wish to change his identity. That 
would involve the obliteration of the memory of his past life, 
of old friends and countless incidents whose recall is one of the 
pleasures of existence. But that is not all which renders the con- 
cept self dear to us; for, in cases of double personality, in which 
the subject has entirely changed his identity through disease, he 
has no desire to return to his former ego. Indeed, he would not 
know of its existence but for some circumstantial evidence. 

A man’s name, which is a symbol of his personality, makes a 
large contribution to his ego-sense. The surname connotes his 

8 


II4 MIND AND ITS DISORDERS 


relationship to his parents and other members of his. family, 
identifies him with them and reminds him of their outstanding 
characteristics. It is, therefore, no small matter for an indi- 
vidual to have been an illegitimate child or to have a convict 
for one of his close relatives. And if a man’s Christian name or 
surname has a meaning or connotation in the ordinary language, it 
is remarkable how frequently this tends to determine his interests. 

Our conclusion is therefore that the ego is a recombination of 
abstractions from many individualities. The City Company 
Promoter has totally distinct individualities when he is doing a 
cross-word puzzle at home, bathing in the sea or reading the 
lessons at church; and his ego is a recombination of abstractions 
from all such personalities. It is difficult to think of the ego in 
terms of the intellect, perception, judgment, knowledge and 
similar functions exclusively; they may help to build it, but the 
most important factors are the person’s wishes and feelings. 

Let us here revert to what was said at the beginning of this 
chapter, viz., that the ego is not unconscious. Indeed no part 
of this concept lies in the unconscious, but it may be admitted 
that it is mainly preconscious and, when we come to think of it, 
this appears to raise the question whether the preconscious 
contains anything that is not a part of the ego. Is not the ego 
more or less identical with the preconscious ? During childhood 
this is true enough while the character is being moulded by the 
parents or their surrogates; but after this period every individual 
comes to rule himself—or ought to do so—by absorbing this 
parental influence into his own mind. This function is what 
Freud has called the Ego-ideal or Super-ego, which is partly 
conscious and preconscious (conscience) but also in part uncon- 
scious. The constitution of the personality may therefore be 
diagrammatically represented thus: 


Conscious 
Conscience 

Preconscious Ego 

° 

80 

fx) 

H 
Unconscious Id &. 

=} 

n 


The Id is the name given to that part of the unconscious which 
contains repressed desires of a libidinous nature, 


MAN AND WOMAN II5 


In childhood narcism or self-love is directed toward the real 
ego. In later life it is transferred to the Ego-ideal or Super-ego. 
A feeling of guilt or inferiority without obvious cause is due 
to conflict between the Super-ego and the Id, as also are self- 
accusations and delusions of being watched in the psychoses. 


PERSONAL DIFFERENCES. 


In the above account of the mental constitution of a normal 
individual we have already seen that certain differences exist 
between people. They differ in their ideational type, in their 
inherited tendencies and in the acquired tendencies which educa- 
tion and environment have given them. Some have a preference 
for saturated colours, others for neutral tints, and so forth. 

It has further been determined that sensation is more acute in 
some people than in others. For example, sensibility to touch 
and pain is keener in town than in country folk, in whites than 
in negroes, among educated classes than among the lower and 
probably in men than in women, although Lombroso and Jastrow 
obtained opposite results in comparing the sexes. Similarly 
men possess a keener sense of smell and of hearing than women. 
With Galton’s whistle it has been found that, as a general rule, 
men can hear the shrillest notes more often than women. On 
the other hand, the sense of taste is keener in women than in 
men, except for salt. There appears to be no marked sexual 
difference in the keenness of healthy vision. 

Woman, then, is on the whole less sensitive than man. On 
the other hand, a woman’s motor response to a stimulus is more 
ready than man’s; she is less sensitive but more irritable, or 
rather, affectable. Insensitiveness and affectability, however, do 
not invariably go hand in hand, for town folk are more affectable 
than country folk and whites are more affectable than negroes; 
while the lower classes are more affectable than the educated. 

The general character of motor reaction in woman as com- 
pared with that in man has probably some connection with the 
relative muscular weakness of woman. Riccardi found that, in 
a series of attempts to exhibit their maximum force with a 
dynamometer, this was attained by the majority of women at 
the first attempt, by the majority of men at the second with 
the right hand; but, with the weak left hand, both men and 
women attained their maximum on the first attempt. 

Woman is quick of perception and ready ofaction. She takes in 
a situation at a glance and acts upon it; man is more deliberate. 
It is always the woman who retrieves a compromising situation. 


LLO MIND AND ITS DISORDERS 


Fatigue shows itself in women more readily than in men. 
This may easily be demonstrated by getting a number of men 
and women to execute a series of rapid tapping movements with 
the finger on a Marey’s tambour connected with a recording- 
drum. It is found that the movements become retarded and 
irregular sooner in women than in men. 

Jastrow has observed some interesting sexual differences in the 
association of ideas. Experimenting with University students 
he got each of them to write down a word suggested by another 
word which he displayed on a blackboard before them. This 
process was repeated with several other words, and from the 
results he concluded that “‘ masculine preferences are probably 
for associations by sound (as man-can), from whole to part (as 
tree-leaf), from object to activity (as pen-write), from activity 
to object (as write-pen) and perhaps by natural kind (as cat- 
dog); while feminine preferences are for associations from part 
to whole (as hand-arm), object to quality (as tree-green) and 
quality to object (as blue-sky) ”’ 

Woman is more emotional and leads a more instinctive life 
than man and this characteristic is nowhere better seen than in 
sexual relationship. ‘“‘A woman loves with her whole soul. 
To her, love is life; to a man, it is the joy of life.’ Woman is 
altruistic, man is egoistic; and this difference, together with many 
others which have been pointed out, is found to produce a marked 
influence on the insanities from which the two sexes suffer. 

These are a few general inductive conclusions; but it is obvious 
to everybody who thinks about the matter for a single moment 
that no two people in the world exactly resemble one another, 
either physically or mentally. It used to be supposed that these 
personal differences are mainly due to inheritance, and this 
belief still holds, to a large extent, in respect of bodily conforma- 
tion; but, chiefly as a result of psycho-analytic investigation, 
the view is gradually gaining ground to-day respecting personal 
dissimilarities of mental constitution that they are principally 
dependent on diversity of experience during the present life- 
history of individuals, especially during early childhood, when 
the mind is developing and being formed. We cannot help 
being differently constituted; every thought, word and action 
throughout our lives is unconditionally determined by previous 
individually diverse experience—plus, of course, the existing 
circumstances of the moment. 

As a matter of fact, psychologists are now pretty well agreed 
as to the truth of this doctrine, and its importance cannot be 


THE UNITY OF MENTATION dtl ty, 


overestimated. It is manifest that educationists and parents 
or their surrogates should ever keep it in view, that clergymen 
cannot afford to disregard it, and that it has some relation to 
every walk of life. Especially we shall find that certain mental 
disorders and nervous symptoms are solely traceable to the 
patient’s past experience of life, and it is probable that, in the 
near future, psychology will play a very important role in deter- 
mining the destinies of man. 


THE UNITY OF MENTATION. 


In the above analysis of mentation it has been found possible 
to consider separately such part-processes as sensation, percep- 
tion, ideation, conception, cognition, recognition, memory, judg- 
ment, reasoning, emotion, action and so forth; but it remains 
to be pointed out that all these processes are interdependent 
and that each, considered by itself, is merely an abstraction. 

As a matter of practical experience even the most primitive 
sensation aroused under the strictest experimental conditions is 
a perceived sensation, and therefore a perception; and it has 
already been said that the perception of an object is but an 
abstraction from the perception of space in general. Further, 
it is a matter of practical experience that the complete percep- 
tion of any given object implies its cognition or recognition. The 
revival of a percept, the formation of an idea, implies an act of 
memory, as also does the formation of a concept. Again, the 
formation of the simplest judgment, true or false, implies an act 
of memory whether it be reliable, erroneous or even unconscious. 
In the case of voluntary action, some zdea of an action must be 
aroused before such action can be performed. A percept or 
idea must be experienced or perhaps a judgment formed ere an 
emotion can be aroused. Lastly it must be remembered that 
every psychical process has its accompanying emotional tone 
and that a complete mental process includes a motor reaction 
resulting from any of the above-mentioned factors. 

We find then that all mental processes considered in the first 
part of this volume are connected together indissolubly; and 
this is no more than might be surmised when we reflect on the 
enormous wealth of association fibres existing in the central 
nervous system between and among the physical bases of all 
these mental processes and on the wealth of mental associations 
originating from temporal or spatial contiguities of previously 
experienced incidents and situations. 


PART IL. | 
PSYCHOLOGY OF THE INSANE. 


Chr heels 
DISORDERS OF SENSATION. 


HAVING considered the way in which the nervous system sub- 
serves the mental functions of a normal individual, it now 
becomes our duty to consider in what way these functions are 
disordered in cases of mental disease. In doing so the several 
mental processes will be considered in the same order as in 
Part li: 

Among the insane, sensation may be altered in one of three 
ways: there may be anesthesia, hyperesthesia or parzesthesia. 
Nearly all the senses may be thus affected and there is a vast 
field for research in this department of psychiatry. 

Cutaneous Analgesia.—The several cutaneous senses may be 
considered together since they are often simultaneously and 
more or less coextensively affected; nevertheless, owing to the 
difficulty of examining the insane, the best criterion of insensi- 
bility is their response. to the prick of a pin, apart from the fact 
that analgesia is much more common and usually more extensive. 
Cutaneous analgesia occurs most commonly in stuporose and 
confusional states. It is found in hysteria, the stadium de- 
bilitatis of acute mania, in katatonia, exhaustion psychoses, 
in alcoholic and epileptic confusion and in many cases of ad- 
vanced dementia. When most extensive the whole surface is 
anesthetic with the exception of a small area in the neighbour- 
hood of the groins and the soles of the feet. The unaffected 
areas commonly resemble bathing-drawers and sandals or, when 
the anzesthesia is less extensive, knickerbockers and boots. In 
the latter case there is commonly a sensitive area in the middle 
of the face. Cases of less severity present analgesia of the legs, 
arms (or forearms) and hands only. This analgesia in its smallest 
extent, as found in some cases of dementia, involves only a few 


small areas of skin on the backs of the proximal phalanges of the 
118 


119 


ANALGESIA IN THE INSANE 


Fic. 21.— EXAMPLES OF ANALGESIA IN 


THE INSANE. 


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ao} Ee = 
Aa, 3.80 
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i) oe OH 
> nwa ss 
p q 77} 

seg Be 
33a BEEGO 

mw 8a ope a 
ES =o 8 9 
ce area 

CS am ba tote 

= oon 
a3 asnod 
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(0) Oe, sO 
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he course of a pro- 
lancholia. 


occurring during t 
longed attack of me 


I20 MIND AND ITS DISORDERS 


fingers. In a few patients exhibiting extensive anesthesia of 
this kind, evidence of loss of muscular or articular sensation is 
shown by their inability to pick up a pin. 

As already stated this loss of sensation is most conveniently 
investigated as analgesia by noting the response of the patient 
to a pin-prick in various parts of the skin. Most patients with 
this anesthesia are stuporose and confused and therefore unable 
to make reliable statements about their symptoms, but in a few 
it is possible to determine that loss of sensation to touch and 
temperature exists more or less coextensively with analgesia. 
It may be taken as a working rule that there is no analgesia of 
this nature in a patient who retains sensation on the back of the 
fingers. Some of these patients have diminution of deep sensi- 
bility to pain, inasmuch as they exhibit a raised threshold to 
Cattell’s algometer. 

I am unable to furnish any explanation of the distribution of 
analgesia in confusional states; but one cannot escape the obser- 
vation that sensation in the genital area is preserved to the 
last, as if to ensure the possibility of reproduction of the species, 
even though this might be of a degenerate type. Another 
observation worth noting is that the analgesia of sleep has this 
same distribution. 

On account of the fact that acute maniacs on the coldest day 
in winter will strip, run into the open ward when covered only 
with a thin cotton nightdress and open all the windows, it has 
been inferred by some authors that they are insensitive to cold. 
This inference is unjustified because it is impossible to detect 
any loss of the cold-sense on careful examination of maniacal 
patients during the acute stage. The tendency of acute maniacs 
to strip is to be explained by their general hyperzsthesia and 
their actions are but an expression of general motor restlessness. 
Doubtless the particular form which this restlessness assumes 
may have some deeper unconscious symbolic meaning. For 
example, opening the windows on a cold day might symbolize 
a desire to cool their passion; but such matters will be discussed 
later. 

Diminution of the visual sense occurs in some patients. Those 
with the peripheral anzesthesia above described frequently have 
contraction of their visual fields, directly proportionate in amount 
to the extent of the cutaneous anesthesia. From the fact that 
they will stare at the sun without apparently suffering any 
inconvenience it is supposed that retinal sensation is diminished 
in some dements, idiots and criminals; but this retinal anzsthesia 


DISORDERS OF SENSATION I2I 


must not be accepted as a fact until it has been experimentally 
demonstrated that such patients are unable to detect minimal 
visual stimuli which are visible to a normal individual. The 
apprehension of colour remains apparently undisturbed in acute 
cases of insanity, but in chronic cortical atrophy and in exhaus- 
tion disorders (accompanied by imperception) there is failure of 
discrimination among the unsaturated colours and among shades 
intermediate in the spectrum between the primary colours. This 
is especially the case with greens and blues. 

The sense of hearing, as tested by the distance from the ear at 
which the tick of a watch may be heard, is deficient in dementia 
and in general paralysis. In the latter this symptom is occa- 
sionally observed in the early stages, the friends of the patient 
volunteering deafness as one of his symptoms on giving a history 
of the case; but perhaps they mistake auditory imperception for 
deafness. Many senile cases of melancholia and in a less degree 
arteriopathic cases are unable to hear tones of very high pitch 
such as are obtainable from a Galton’s whistle; this may be due 
to senile sclerosis of the tympanum. Deafness is occasionally 
the cause of mental disorder as in certain cases of deaf-mutism; 
'it favours the onset of auditory hallucinations and even in the 
sane is apt to give rise to the suspicion that others, taking ad- 
vantage of the patient’s infirmity, are talking about them. The 
deaf are thus rather predisposed to insanity. 

The senses of taste and smell are diminished in dementia, 
general paralysis and some confusional cases. General paralytics 
usually take a lot of salt, and general observation has led me 
to the conclusion that a person’s desire for salt varies inversely 
with his intellectual capacity. It has been stated that there is 
also loss of taste and smell in anergic stupor; the statement 
is probably true, but obviously difficult to ascertain. Some 
melancholiacs cannot appreciate flavours. 

The genital sense is usually diminished in melancholia, epilepsy, 
senile dementia and, after the initial stage, in general paralysis. 
It is completely absent in some cases of neurasthenia. 

The only visceral sensations whose disorder demands special 
notice are those associated with the alimentary canal. The 
appetite is lost in a very large number of the acute insanities; 
this 1s so marked a symptom in melancholia that in many cases 
there is absolute loathing of food. In katatoniac excitement 
also, loss of appetite and consequent refusal of food are the rule; 
these symptoms are but occasional incidents in other forms of 
excitement. Loss of the sense of distension of the rectum is not 


I22 MIND AND ITS DISORDERS 


an infrequent occurrence, especially in melancholia and in the 
tabetic form of general paralysis. In the latter case it is a 
symptom of the tabes, not of the general paralysis; in the former 
it may be due to apathy. This symptom is not to be confounded 
with loss of the instinct of cleanliness, such as occurs among 
advanced dements and other degraded patients. The condition 
here referred to may be instanced by quoting the case of a melan- 
choliac musician who, when his mental symptoms had apparently 
passed off, would sit at the piano and play the instrument bril- 
liantly until he felt that he had unconsciously evacuated his 
rectum during the performance. He completely recovered from 
his attack. 

Similarly the sense of bladder distension may be absent in 
some Cases. 

Hyperesthesia of the various senses is difficult to determine. 
Most observers are agreed that the symptoms of acute mania 
justify the conclusion that all the senses are abnormally keen 
in that condition. Hyperacuity of hearing is undoubtedly 
common among maniacal patients; they can often hear a 
whispered conversation at a distance of ten or fifteen yards. In 
cases of neurasthenia and hysteria it is common for many of the 
senses to be exalted; and melancholiacs are peculiarly sensitive 
to noise. 

The genital sense has been supposed to be hyperesthetic in 
the early stages of general paralysis on account of the increase 
of the sexual instinct. It is found on inquiry, however, that 
there is no increase of the genital sense proper; the desire for 
sexual intercourse is undoubtedly increased in general paralysis, 
but the patient is frequently unable to complete the act and he 
is as likely as not to go to sleep in the middle of it. In cases 
of extreme peripheral analgesia the pelvic area, being the only 
sensitive part of the surface, dominates the consciousness of the 
patient and he is apt to commit indecent acts, especially to 
masturbate. It would be erroneous to conclude that in these 
cases there is tvue hyperzesthesia of the external genitals, since 
the rest of the cutaneous surface is anesthetic; there is relative 
hypereesthesia. 

Increase of the appetite for food must be distinguished from 
increase of the eating instinct. The general paralytic and the 
chronic dement in some stages eat enormously, not so much 
because they are hungry as because they are greedy. Some 
maniacs eat voraciously because of their enormous appetite; and 
there is one disorder in which increase of the appetite for food 


DISORDERS OF SENSATION 23 


is one of the most marked symptoms, viz., hypochondriacal 
paranoia. Hypochondriacs (not hypochondriacal melancholiacs) 
are always hungry. 

Pareesthesize of the various senses are of frequent occurrence 
among the insane; they are of the nature of simple illusions or 
hallucinations and are therefore considered under these headings. 

Erroneous localization is a symptom which frequently occurs 
in cases due to coarse lesions of the cerebral cortex and in some 
lesions of the spinal cord; but it occurs very seldom in functional 
disorders. In my practice I have met with only one such case; 
the patient was suffering from epileptic confusion and extensive 
anesthesia, sensation being retained in small patches in the 
groins and on the soles of the feet only; there was also contraction 
of the visual fields. The interesting point about this patient was 
that, in the areas which retained sensation, a pin-prick stimulus 
was invariably referred to the corresponding spot on the opposite 
side (allocheiria). 

Whether the duration of sensations in the insane differs from 
that of the sensations of the healthy has not been investigated. 

Hysterical disturbances of sensation, such as local anzsthesias, 
| hypereesthesias, pains, blindness and deafness, are of purely 
psychical origin, being invariably a compromise between an 
unconscious wish and repressing forces. 

Examples were common enough during the War and were 
diagnosed as “shell-shock’’. One type will suffice. The 
soldier's unconscious wish was to see the Germans blown to 
atoms; consciously he had no desire to see such a horrible 
spectacle. When, therefore, he actually saw arms and legs 
hurtled through the air he became blind, thus satisfying both 
conditions. The unconscious was excused from seeing its wish 
fulfilled, while the conscious was spared the pain of observing 
repeated mutilations. Of course, quite a small proportion of 
our millions of soldiers at the front suffered in this way, although 
they were all exposed to the same conditions. This was due to. 
the fact that there were deeper-lying personal factors in the 
causation of these cases of hysterical blindness and of all similar 
conditions, the nature of which will be discussed in subsequent 
chapters. 


CPNVE DE RSE 
DISORDERS OF PERCEPTION. 


THERE are three disorders of perception, viz., imperception 
(including “‘ inertia of ideation ’’), hallucination and illusion. An 
example of each will suffice to explain the meanings of these 
terms. Let us start at the beginning. When a cigar lies on 
the table before me and I see it and know that it is a cigar, the 
process is one of perception; when there is nothing on the table 
and I think of some cigar lying there, the process is one of idea- 
tion; when there is a pencil lying there and I look at it and see, 
not a pencil, but a cigar, the process is one of illusion; when there 
is nothing on the table and I see a cigar lying there, I experience 
an hallucination and lastly, if a cigar lies on the table, and I see 
it but cannot tell what it is, I am suffering from imperception. 


IMPERCEPTION. 


) 


Of late years this symptom has also been called “ agnosia ’’. 
Patients suffering from imperception or agnosia are able to see, 
hear, feel, taste and smell objects in their environment; but 
they are unable, in spite of extended previous experience of such 
objects, to place ideational content in the sensations aroused by 
them. 

The student is already familiar with such a state of affairs in 
the domain of word-perception. Patients suffering from word- 
blindness can see the printed page, but they cannot read it: the 
words convey no meaning. If you address a patient suffering 
from word-deafness, he hears you, but he cannot understand 
what you are saying; you might as well address him in ancient 
Greek. Here we have to deal with verbal imperception or verbal 
agnosia. With these special forms of imperception we shall deal 
in a later section; we are now speaking of imperception, not of 
verbal symbols of objects, but of the objects themselves. 

If a patient is given a bottle of oil of cloves to smell and he 
tells you that he can smell it, that the odour is familiar, but 


that he cannot tell what it is, he is suffering from olfactory 
124 


DISORDERS OF PERCEPTION I25 


imperception. If you give him syrup to taste and he tells you 
that he can taste it but cannot tell what sort of a taste it is, that 
is gustatory imperception. If you show him a button-hook and 
he cannot tell what it is, you have a case of visual imperception. 
If you jingle a handful of coins behind his head and he says that 
you are shaking a box of pills, he is afflicted with auditory 
imperception. If you place a pair of scissors in his hand and 
get him to feel them without looking at them and he says that 
the object is a key, this would be tactile imperception, some- 
times incorrectly called “ astereognosis ’’. 

It must be left to the physician’s own resources to provide 
himself with convenient tests for imperception. Inasmuch as 
there are various degrees of imperception it is advisable for him 
to carry in his pockets a few objects of unusual construction such 
as a fancy match-box, a pencil-case and a knife with some un- 
common implements in it. I have a small metal paper-knife 
with a good-sized lens in the handle, which is usually somewhat 
of a puzzle to arteriopaths. Such sounds as the tearing of paper 
and the “‘siss”’ of a soda-water siphon in action are good tests 
for auditory perception. 

Pictures are useful tests for visual perception. For severe 
cases I use one of Dean’s rag-books for children, called “‘ Baby’s 
Object-Book’”’. It contains pictures of several common objects 
with their names printed below; and a patient under examina- 
tion is required to recognize the objects depicted therein, the 
names being covered up. In order to detect slighter degrees of 
imperception I use another picture-book for children, entitled 
“ Proverbs Old Newly Told’”’. Each picture represents some 
well-known proverb which the patient under examination is 
required to recognize, the proverb itself being covered up. Of 
course, only those pictures which tell their tale well should be 
employed. 

The name “‘ asymboly ”’ has been given to a form of impercep- 
tion in which only the terminal stage of perception is wanting, 
the stage in which a given object has to be referred to some 
concept derived from the past experience of the individual. For 
example, a man is shown a button-hook. He says: “This is 
evidently a handle, and this is evidently a hook for holding 
something.”” You reply: “‘ Quite right; what is the article ?”’ 
He replies: “‘ I don’t know; it is just a hook for holding some- 
thing.”’ Again, you place a half-crown in his hand, without 
allowing him to see it. He says: “‘ That is a metallic disc with 
a thickened rim; the edge of it is rough, and there appears to 


126 MIND AND ITS DISORDERS 


be an embossed design on either side of the disc.’’ You reply 
“Well, cannot you tell me what the article is ?”’ and he answers 
“No, I can tell you nothing more about it.” You then tell him 
to look at it, and he will probably say: “ Why, it’s a half-crown !” 
—Tactile asymboly. 

Agnostic perseveration or ideational inertia is a symptom 
closely allied to imperception. Patients exhibiting this phe- 
nomenon appear to be unable to get rid of an idea. A few 
examples will serve to iulustrate the symptom. A man is shown 
a pencil; he recognizes it and says it is a pencil. He is now 
shown a match-box; he says it is a box for holding pencils. He 
is next shown a paper-knife; he says it is a knife for sharpening 
pencils. Take another case: A patient is shown a button-hook; 
he recognizes it and says it is a button-hook for fastening boots 
and shoes. He is now shown a knife; he says “ That is for 
boots and shoes too!’’ He is next shown a silver match-box; 
and he says “‘ That also is for boots and shoes ’”’, and so on. 

Imperception, like other symptoms of mental disorder, exemph- 
fies the principle that dissolution is a reversal of evolution. 
There is a stage in the history of every child in which true percep- 
tion of an object does not occur because the child has not yet 
had experience of such objects. In dissolution the adult reverts 
to this stage, his ability to take advantage of his previous experi- 
ence having been obliterated by the ravages of disease. Idea- 
tional inertia is also met with in childhood, generally about the 
fourth or fifth year. Those who have had experience of ‘children 
will think of many instances. 

The Physical Basis of Imperception.—Imperception occurs in 
association with disease of the cerebral arteries, in states of 
exhaustion, in acute and chronic alcoholism and in other intoxi- 
cations. Now these are exactly the conditions (intoxications 
and interference with the blood-supply) which are known to 
react most unfavourably upon the synapses.* We may there- 
fore safely assume that the physical basis of imperception con- 
sists of an increase of synaptic resistance within the association- 
areas. Further evidence is given in later chapters. This same 
increase of synaptic resistance will account for the phenomena 
of ideational inertia. 

Systematized Anzsthesia.—Although this disorder is a lack 
of perception, it is in no way related to the imperception above 
described. It occurs in some cases of hysteria, and patients 


* Sherrington, “‘The Integrative Action of the Nervous System”’, 
chap. i. 


HALLUCINATIONS 127 


manifesting the symptoms are unable to see, hear or feel a certain 
person or object in the room, such person or object being usually 
objectionable to the patient. Perception is otherwise normal, 
and there is little mental confusion; it is merely that the said 
person or object does not exist for the patient. The condition 
is a simple exemplification of the general principle that all 
neurotic and psychotic manifestations fulfil an unconscious 
wish. The patient does not see or hear a person because he 
does not wish to do so. Hurst, who belongs to another school 
of thought, half realizes this factor when, in his Croonian Lec- 
tures, he states that an hysterical patient does not see because 
he does not look and does not hear because he does not listen. 
This way of putting it is very near the truth. 


HALLUCINATIONS AND ILLUSIONS. 


An hallucination may be defined as a percept experienced in 
the absence of any peripheral stimulus to cause such percept. In 
illusion, peripheral stimulus is present, but not that stimulus which 
would normally cause the particular percept experienced. For 
example, if a person sees a ghost on a pitch-dark night or hears 
bells ringing when all is silent, he is suffering from an hallucina- 
tion; but if a will-o’-the-wisp appears to him as a ghost or if he 
mistakes the chirp of a cricket for the sound of church bells, he 
is suffering from an illusion. It must be distinctly understood 
that the hallucinated person does not think he sees a ghost, he 
does see a ghost; he does not think he hears bells, he does hear 
bells. 

Hallucinations are classified according to the sense-modality 
in which they are experienced; thus there are hallucinations of 
vision, hearing, smell and taste. There are also hallucinations 
of touch, pain, and temperature, sexual hallucinations and 
psycho-motor hallucinations of movement. 

These perversions of perception may occur in the sane as well 
as the insane. They are familiar to all of us in dreams and 
in the hypnagogic state (state between waking and sleeping) ; 
and they are liable to occur in association with the pain of 
visceral disease. In the sane visual hallucinations are more 
common than auditory; in the insane the reverse is the case. 
Auditory hallucinations are more lable to occur in the insanities 
of later life, visual in those of early life. 

Hallucinations are either simple or complex, the complex being 
mostly auditory or visual. To the class of simple hallucinations 
belong vague shadows or flashes of light (photopsia), buzzing in 


128 MIND AND ITS DISORDERS 


the ears and hallucinations of taste and smell. To the class of 
simple illusions belong such pareesthesiz as the epigastric and 
abdominal sensations described below, parageusia in which the 
food tastes as filth, and “‘ secondary sensations ’’’. Some of these 
simple sensations are of considerable assistance in helping us to 
understand the nature of hallucination and therefore require 
careful consideration. 

About 27 per cent. of the insane suffer at some time or other 
from the “ epigastric sensation ’’ or from some allied sensation 1n 
the neighbourhood of the abdomen or lower part of the chest. 
This sensation is usually described as a sinking feeling but it 
may be a feeling of fulness or even of pain. In its commonest 
form it is experienced by the healthy on the receipt of bad news; 
and it was owing to the frequent occurrence of such sensations 
that the ancients regarded the heart, liver, spleen and intestines 
as the seat of the passions. Even to-day we hear of a “ hard- 
hearted ’’ man “ venting his spleen”’ against another, and the 
same notion has given us the names “ melancholia ’’ (black bile) 
and “‘ hypochondriasis ’’ (under the ribs). . 

Epigastric and allied sensations most commonly arise in con- 
fused and stuporose states. The epigastrium is the commonest 
situation, but the umbilical region, the hypogastrium and the 
external genitalia are frequent sites of similar sensations. Such 
feelings are occasionally referred to the sternal region and it is 
possible that such symptoms as “ globus hystericus ’’, “ neurotic 
spine’, “hysterical hip’’ and “hysterical shoulder’’ may 
sometimes be partially of the same nature. 

A large number of cases presenting the above symptoms have 
peripheral analgesia; and, conversely, all patients with well- 
marked peripheral analgesia, who are capable of making any 
reliable statement about the matter, when interrogated as to the 
presence of an epigastric or allied sensation, answer in the affirma- 
tive and it may be inferred that the sensation exists more or less 
in all such patients. Further, although some patients have 
the abdominal sensation without obvious peripheral analgesia 
many of these tell us on examination that they do not feel a 
pin-prick so well on the hand as on the trunk. It is therefore 
justifiable to infer that patients having the abdominal sensa- 
tion have more or less peripheral analgesia, in some cases to a 
very slight degree, occasionally so slight as to elude detection. 
One patient in Bethlem Hospital, whose symptoms suggested 
such a view, was a neurasthenic who complained simultaneously 
of a “‘ burning sensation’ in the hypogastrium and of “ loss of 


THE EPIGASTRIC SENSATION I29 


feeling ’’ in the legs, but I was unable to detect by crude methods 
of examination any objective loss of sensation. 

It is therefore to be concluded that the epigastric and allied 
sensations arise when there is some loss of sensation in the 
peripheral parts of the organism. In patients with analgesia of 
this distribution, consciousness is mostly dependent on sensa- 
tion derived from the abdomen, the more or less anesthetic parts 
contributing little or nothing to the content of consciousness. 
The abdomen and neighbouring parts thus “have greatness 
thrust upon them ”’ and claim a large amount of attention; in 
this way they become the seat of abnormal sensations. 

The epigastric aura of epilepsy is a particular example of 
epigastric sensations in general; it occurs when the patient is 
losing consciousness, in other words, is losing sensation; and it 
may be gathered that loss of sensation at the onset of an epileptic 
fit sets in at the periphery, that the patient at this stage experi- 
ences the epigastric aura and that the last event before the 
patient falls is loss of sensation in the abdomen. Dr. Collins, 
when superintendent of the L.C.C. Epileptic Colony, told me 
that he could confirm this hypothesis, since he had discovered 
peripheral anzsthesia in an epileptic during a prolonged aura. 

Abdominal discomfort is also liable to arise in certain anxiety 
states, especially in the anxiety neurosis and anxiety hysteria. 
The pathology of this condition will be described Jater. For the 
present it is to be noted that it is quite different from that of 
the sensations above described. 

Syneesthesiz or secondary sensations are those which accom- 
pany sensations of another modality; for example, some people 
experience with every auditory sensation an accompanying visual 
sensation: the tone G is perhaps associated with the colour red 
or the tone D with blue. Similarly sensations of colour may 
accompany perceptions of taste, smell, touch, pain, heat or cold: 
they are called “‘ photisms’’. With some people certain words 
are accompanied by a sense of colour, varying with different 
words (verbochromia). Again, there are secondary auditory 
sensations called “‘ phonisms ’’, secondary taste sensations called 
“ sustatisms ’’, secondary smell sensations called “ olfactisms ”’ 
and so on. These secondary sensations are here mentioned 
because they throw light on the nature of hallucinations and 
illusions by demonstrating that, at least in some people, the 
visual centre may be stimulated by way of association-fibres 
from the auditory, gustatory, olfactory and other centres and, 
vice versa, that each of these centres may be stimulated by way 

9 


I30 MIND AND ITS DISORDERS 


of association-fibres from any other centre. Secondary sensa- 
tions are not especially associated with insanity. The nearest 
approach to them encountered among the insane occurs in some 
cases of simple melancholia. Some of these patients say that an 
object, usually white or black, will appear, for example, green for 
a few seconds. This phenomenon, probably due to some un- 
conscious symbolic meaning of the colour green for that particular 
patient, would be classed as a simple illusion. 

Complex hallucinations of hearing are usually “‘ voices ’’, some- 
times a babble of voices so that the patient is unable to distin- 
guish what is said, sometimes a single voice making taunting 
or other offensive remarks; occasionally there is even greater 
complexity, as in the case of a patient who used to hear lectures 
an hour long on Chinese literature, a subject of which he knew 
nothing. It must not be supposed that these “‘ voices ”’ are in- 
distinct and muttering; on the contrary, they are usually dis- 
tinct and often very loud, so loud indeed that I have met patients 
to whom it was necessary to shout in order to be heard above 
the voices. In some cases these assume a tone of command; 
such hallucinations are particularly dangerous since the patient 
is apt to obey any hallucinatory suggestion to commit suicide or 
homicide. In some cases there are two voices, one persecuting 
the patient and the other taking his part; it is said that such a 
condition points invariably to chronicity. 

Other complex hallucinations of hearing are church bells or 
music, sometimes of an orchestra in which the various instru- 
ments can be clearly distinguished. 

The apparent source of an auditory hallucination varies in 
different patients: in decreasing order of frequency it is (I) over- 
head, (2) under the floor, (3) on the same level as the patient’s 
head. This order of frequency has obvious relationship to the 
facts mentioned on p. 41. 

The role of the “ unity of ideation ’’ in determining the apparent 
source of an hallucination of hearing is dealt with later. 

It has been said that, when hallucinations of hearing are 
constantly referred to one side, the symptom is indicative of 
coarse brain disease; this is not in accordance with general 
experience. In cases of unilateral deafness from any cause 
auditory hallucinations are liable to occur on the deaf side only, 
but a few cases are recorded in which the hallucinations were on 
the side opposite to the deafness. Apart from such patients the 
affected side is usually the left.and the patients thus afflicted 
commonly show hysterical symptoms, especially comparative 


COMPLEX HALLUCINATIONS I3I 


hemi-anesthesia of the right side. These conclusions are derived 
entirely from observations made on right-handed patients. | 

The deaf, but not the congenitally deaf, are especially liable 
to hallucinations of hearing; it is said that Beethoven after he 
became deaf heard in hallucination (or was it in ideation ?) 
many of his earlier compositions. 

Except in certain toxic cases, auditory hallucinations are, as 
a rule, of evil prognostic significance; the exceptions to this rule 
may sometimes be recognized by getting the patient to ascertain 
whether he can still hear the sounds when his ears are stopped. 
In the majority of cases they are no longer heard; but if they 
still persist, the prognosis is more favourable since the patient 
either believes or may be reasoned into the belief that the sounds 
are hallucinatory. The result is obviously one of expectancy on 
the part of the patient since the question whether he will or 
will not hear the sounds with his ears stopped depends on the 
depth of his belief in their reality; and the physician has already 
done much toward the relief of his patient if he has convinced 
him of the hallucinatory nature of the sounds he hears; he has 
given him considerable insight into the nature of the malady. 
This can occasionally, though rarely, be done by a suggestion to 
the patient that, when he tries the experiment, he will hear the 
sounds with his ears stopped. 

Complex hallucinations of vision usually take the form of 
faces; but in some patients they attain the most extraordinary 
complexity. The late Dr. C. E. Beevor once told the author 
of an epileptic whose aura consisted of the following visual 
hallucination: Thirteen men stood before him, the first turned 
and walked away, the second turned and walked away, the third 
did the same, and so on until the last man hit the patient, and 
he had a fit. 

Visions may be pleasant or unpleasant. In some exhaustion 
cases they are so pleasing that the patients like to keep their 
eyes closed in order to enjoy to the full the beautiful scenes of 
their phantasy, while in delirium tremens the patient is terrorized 
by the horrible beasts he sees around him. 

Sensations of light are experienced by normal individuals when 
pressure is made upon the eye or after it has been struck. Such 
sensations, which are known as “ phosphenes ”’, are due to direct 
stimulation of the retina. Now in delirium tremens and, very 
rarely, in some other conditions phosphenes are liable to appear 
to the patient as pictures. Under such circumstances these 
apparitions are usually spoken of as hallucinations; it is really 


132 MIND AND ITS DISORDERS 


more correct to call them illusions. They are easily induced by 
light pressure on the closed eyelids of such patients and the 
figures in such apparitions are usually in movement. 

Moving objects in hallucination usually pass from left to right 
or make their appearance to the left of the patient, advance and 
disappear in the distance. This is the rule for right-handed 
patients; in left-handed patients the movement is usually from 
right to left. Right and left have a deeper significance for the 
unconscious than for the conscious mind. They mean more than 
one side and the other side of the body; the left is the weak and 
awkward side: hence right and left may symbolize right and 
wrong in various senses in different patients. 

Hallucinations of vision may occur in the blind; they may 
also occur in a single blind eye or even in a hemianopic field. 
In the last case they are usually of a simple variety (lights). 

Visual hallucinations are usually black, white and grey like 
shaded drawings, especially in the more chronic forms of in- 
sanity; coloured visions more frequently occur in the acute forms 
(exhaustion psychoses). 

Tests of prognostic significance, similar to that mentioned in 
the case of auditory hallucinations, may be applied to visual. 
The patient is directed to close his eyes when he has a vision; 
if it disappears, the prognosis is less favourable than if it remains. 
Hallucinations are never doubled by pressure upon one eyeball, 
because such doubling of objects is not a sufficiently common 
everyday experience to form part of a patient’s ideational equip- 
ment. Hypothetically, if an hallucination were thus doubled 
the prognosis would be hopeless. 

Hallucinations of both vision and hearing are most frequent 
at night when all is dark and quiet. 

Hallucinations of smell may be pleasant or unpleasant. If 
pleasant the odour is compared to that of flowers, fruits or 
artificial scents; if unpleasant—and this is more common—it is 
compared to the odour of feces, rotting corpses or something 
burning. 

Sir George Savage has stated that there is some relationship 
between hallucinations of smell and disorders of the sexual 
organs and function. With this the author is disposed to 
agree, although the statement has not been allowed to pass 
unchallenged. 

Dr. Hughlings Jackson pointed out that the olfactory aura 
of epilepsy is frequently associated with a ‘‘ dreamy sensation ’’, 

It is probable that many hallueinations of taste are dependent 


OTHER HALLUCINATIONS 133 


on a dirty condition of the patient’s mouth and should there- 
fore be regarded as illusions. They are almost invariably un- 
pleasant and may give rise to ideas of poison. 

Hallucinations of pain affecting the cutaneous senses occur 
most frequently in some delusional forms of insanity, but not in 
paranoia. Asarule, they are referred to the neighbourhood of the 
abdomen and are described as electricity, magnetism, hypnotism 
or some other form of unseen agency. Unconscious homo- 
sexuality and anal erotism cause some patients to complain of 
painful prods, pricks, stabs, shocks or darts, almost invariably 
in the back (the disguised fulfilment of unconscious wishes); 
but occasionally their unusual character may cause a patient to 
coin a new word (neologism); he is ‘“‘ spreethed’’, ‘‘ spored”’, 
“ cheefened’’’, “‘torched”’, “‘ petered in a hodge-podge”’ or 
otherwise tortured by a “ teleform switch-battery confederacy 
of blacklegs ”’. 

Pain and other sensations sometimes occur as an hysterical 
symptom. In such a case the sensations are usually more per- 
sistent and the patient does not misinterpret their meaning 
so grossly as the patients above cited, although the psychical 
mechanism responsible for the hallucinations may be very 
similar. 

Hallucinations of warmth commonly extend all over the 
surface of the body. They are common in melancholiacs and in 
cases of paralysis agitans; many of these patients protest that 
they feel quite warm when they are blue with cold. It is true 
that many melancholiacs make such protests in order to avoid 
the association with other patients round the fire, but there is 
no doubt that in many cases the statements are perfectly true. 
With other patients, again, the hallucination amounts to a feeling 
of actual heat causing them to believe that an unseen fire is 
raging around them. 

Hallucinations of cold are rare; they may occur locally or 
generally. In some cases a feeling of warmth is “shot over ”’ 
the patient and this is succeeded by a feeling of cold. 

True tactile hallucinations are occasionally, but rarely, met 
with. Their most usual form is perhaps the feeling that insects 
are crawling over or under the skin; but it is possible that tactile 
hallucinations are frequently overlooked, since patients would 
not complain of them unless they were unpleasant. They are 
possibly sometimes an element in the feeling of moisture, dryness 
or dirtiness occasionally complained of by patients, the other 
element being a sensation of cold or warmth. The occurrence 


Loa MIND AND ITS DISORDERS 


of these hallucinations of moisture has given rise in the Italian 
school to the notion that there exists a distinct “‘ hygric ’’ sense 
and they have been called “ hygric ’’ hallucinations. One writer 
goes so far as to localize in the hippocampal gyrus a special 
centre for sensations of moisture. Although no “ hygric’”’ sense 
has ever been demonstrated, the feeling of moisture or wet-_ 
ness is a matter of common experience. It is a percept on a 
higher plane than sensation; so are the feelings of dryness or 
dirtiness. 

The feeling, of which some patients complain, that there is 
somebody behind them and perhaps looking over their shoulder, 
might possibly be classed as a tactile hallucination. 

The “‘ abdominal sensation ’’ and its congeners are sometimes 
definitely tactile, but they are usually referred to the cesophagus, 
stomach or intestines. Such sensations are then called “ visceral 
hallucinations ”’ (q.v.). | 

Sexual hallucinations are frequently met with, not merely 
cutaneous sensations in the neighbourhood of the external geni- 

alia, but specific sexual sensations accompanied by orgasm. 
In women these apparently lay a foundation for delusions of 
rape, but probably the more correct view is that the delusions 
and the hallucinations are parallel symptoms, both of which 
gratify an unconscious desire. | 

Perhaps the most interesting of all hallucinations are the 
psycho-motor. These consist of a feeling of movement of some 
part without any movement actually taking place. Most 
commonly this feeling of movement is in the mouth, the patient 
feeling that he is saying words under compulsion. Patients 
often complain most bitterly that obscene and blasphemous 
words are thus forced, as it were, into their mouths, words which 
they would be the very last people to use in their normal state 
of health and of which they have an utter abhorrence. Such 
hallucinations may induce the patient to believe that she (for 
these notions are more common in women) thinks aloud or that 
people are able to read her thoughts. Psycho-motor hallucina- 
tions may also be referred to other parts of the body. For 
example, one patient used to have the feeling that her arm had 
darted up and struck a nurse and she always had to be reassured 
that nothing of the kind had happened. Another used to feel 
her hand pass to her head and pluck a hair, although she could 
see her hand lying by her side. Another would complain that 
she was made to breathe too quickly or too deeply, her respira- 
tion being quite normal. 


OTHER HALLUCINATIONS 135 


This last is one of the forms of the so-called “ respiratory 
hallucination ’’. Another feeling which some writers have de- 
scribed as a “‘ respiratory hallucination ”’ is a complaint of some 
melancholiacs that they have “no breath’’. The nature of this 
sensation will be more fully comprehended when the general 
principles of melancholia have been studied. 

Hallucinations of the static sense sometimes occur. The 
author has notes of only two such cases; both complained of 
feeling upside down and falling. One was suffering from acute 
confusional insanity and made a very fair recovery; the other 
was a Jewess suffering from katatoniac stupor who did not 
recover. In neither case was it possible to ascertain whether 
the sensation was that of falling head first. However, we learn 
from psycho-analytical experience that “ falling’? commonly 
symbolizes “‘ falling’’ in a moralsense. The vertigo experienced 
by patients suffering from labyrinthine disease or from lesions of 
the cerebellum is scarcely to be classed as a true hallucination. 

We occasionally come across an hallucination of such a nature 
that it is difficult to determine to which sense it should be assigned. 
As an example may be quoted the case of a Bethlem patient 
_ who felt the earth to be constantly heaving or trembling like a 
jelly under his feet. We cannot be quite certain whether this 
sensation is to be referred to the skin, muscles or joints. 

In the acute stage of delirium tremens and, very rarely, in 
some other mental disorders hallucinations may easily be sug- 
gested to the patient. If you say to him “ Look at that great 
spider crawling towards you ”’, he will see a spider and be terrified 
by it; if you say “ Listen to the noise of the machinery ’’, he will 
hear it and perhaps say that he hears the engines of torture; if 
you say.“ Do you smell those flowers ?”’ he will reply in the 
affirmative, and so on. 

Hallucinations of some kind or other occur in about 70 per 
cent. of the insane, hallucinations of hearing in about 50 per 
cent. In about 30 per cent. of patients one sense only is affected 
in this way, in 20 per cent. two senses are affected and in Io per 
cent. three senses. A few patients suffer from hallucinations of 
five, SIX or even more senses. 

At the beginning of this study of hallucinations a distinction 
was made between these and illusions; but it has already been 
seen that it is not always an easy matter to decide whether a 
given sense-perversion should be classed under one heading or 
the other, especially in the domain of smell or taste. The same 
difficulty may arise in those cases in which illusions arise as a 


136 MIND AND ITS DISORDERS 


result of an irritative lesion of some sensory nerve. The false 
perception will be called an hallucination if a diagnosis of the 
irritative lesion has not been made. In some hysterical cases 
the site and nature of an hallucination may be determined by 
an organic lesion. For example, in a recent case of anxiety. 
hysteria due to an ungratified sexual passion the patient heard 
various sounds possessing a sexual symbolism (guns, lighted 
candles, bells etc.) in her left ear, from which she had had a 
discharge since infancy. She had a mastoid operation, but this 
did not cure the hallucinations. These are the cases which 
Freud calls “ Fixation Hysteria ”’ 

It is a question whether the epigastric sensation should be 
regarded as illusion, hallucination or even percept. 

Apart from these cases, illusions of whose nature there is no 
possible doubt are frequent in the insane. Many patients are 
liable to mistake the identity of those about them. The doctor 
is greeted as the patient’s father, brother or husband and the 
matron as sister or mother. At Bethlem Hospital a former head 
male attendant used to be constantly mistaken for His Majesty 
King Edward VII., especially by exhausted patients, although 
that official bore no extraordinary resemblance to our lamented 
Sovereign. 

It is convenient to adhere to this old classification of hallucina- 
tions under the headings of the various sense-modalities to which 
they are referred; but many of our examples demonstrate that 
hallucination does not lie in the plane of sensation, but in that of 
perceptual experience. To this matter we must return later. 

The physical substratum of hallucinations and illusions will be 
clear to the student who has grasped the fundamental principles 
of normal perception and ideation. 

Our studies in the first section of this manual taught us that 
perception consists of two part-processes, a physical and a 
psychical. The physical process in perception is the stimula- 
tion of an association-centre (ideational centre) by the media- 
tion of a corresponding end-organ, the psychical process being 
the feeling that there is ‘something there’’, and ideational 
content derived from experience is placed in the ‘“ something 
there™’, 

It is clear that, in hallucination and illusion, the psychical 
process is identical with that of perception; the difference 
between these processes is therefore to be sought in the physical 
mechanism and there is no difficulty in discerning wherein this 
difference lies. 


PATHOLOGY OF HALLUCINATIONS LS, 


For the sake of simplicity let us limit our considerations to 
the domain of vision and, for example, let us take the process 
of seeing an orange on the table. In perception an orange lies 
on the table and I see it, in illusion a biscuit lies on the table 
and I see an orange, in hallucination I see an orange when there 
is nothing there. 

Now by studying hallucination in the insane, the writer has 
determined that there is a negative as well as a positive side to 
the hallucination process. To keep to our example, the positive 
side is that I see an orange, the negative side is that I do not 
see the table in the neighbourhood of the orange. It is with the 
utmost difficulty that patients with hallucinations of vision can 
see objects in the neighbourhood of an hallucination image (in- 
deed the effort to do so may dispel the hallucination) ; and, during 
hallucinations of hearing, patients can hardly hear real sounds. 
I have known several patients with whom auditory hallucinations 
were unceasingly present and to whom it was necessary to shout 
in order to make my voice heard. All of these patients recovered 
and were not deaf when the hallucinations ceased. If, as in 
some cases, the negative factor is wanting, the patient voluntarily 
supplies it; exhausted maniacs frequently keep their eyes closed 
in order to favour the formation of pleasant visions or keep their 
hands over their ears in order to favour pleasant auditory 
hallucinations. 

The probable explanation of the negative factor is that the 
neurons, which normally conduct sensations from the end-organ 
to the cortex, are dissociated from one another, presumably by the 
retraction of gemmules. The positive factor, that I see an orange 
when there is nothing there, means that the ideational centre 
behind the angular gyrus is stimulated by way of association- 
fibres other than the occipito-angular bundle. That this is 
possible is indicated by the existence of “‘ secondary sensations ”’. 

The hallucinated state is also favoured by the absence of 
sensations of other modalities than that affected. It is for this 
reason that hallucinations are most frequent at night when small 
stimuli by way of association-fibres do not pass unheeded, but 
induce a physical state with which a correlative “ something- 
there ’’ psychical process occurs. The absence of other stimuli 
allows the affected sensory area to dominate consciousness, idea- 
tional content is placed in the “‘ something-there ’’, and the result 
is hallucination. This principle was illustrated by the case of 
a lady who, during the delirium of typhoid fever, was afraid to 
close her eyes at night because, when she did so, she heard in 


138 MIND AND ITS DISORDERS 


hallucination horrible sounds apparently proceeding from a dis- 
cordant brass band; during the day the music was pleasant and 
she would close her eyes in order to hear it. In this case visual 
stimuli were sufficient to inhibit the auditory hallucination. 

The two factors, diminution of sensation and disturbance of 
association, upon which hallucination depends, vary inversely 
in the several conditions in which it occurs. For example, in the 
delirium of fever and in the motor excitement accompanying 
some states of exhaustion there is little anesthesia and great 
disturbance of association, whereas in cases of nitrous oxide or 
chloroform inhalation there is marked anesthesia and little 
disturbance of association. 

Illusion differs from hallucination in that there is no peripheral 
dissociation. 

It will not have escaped the reader that the physical mechanism 
of hallucination is precisely the same as that of ideation. The 
psychical differences are that the hallucination image is vivid 
while the ideational image is faint and that the ideational image 
is accompanied by a sense of past direction in time (then-ness) 
while the hallucination image is accompanied by a sense of the 
present (now-ness). 

The above theory of the nature of hallucinations receives 
support from the fact that, under certain circumstances, mere 
suggestion suffices to induce hallucinations. They may be so 
induced in hypnotized persons and even, by means of the follow- 
ing laboratory experiment, in normal individuals. 

A blue bead, 14 inches long by # inch wide, is suspended against 
a black background. This is shown to an observer, who walks 
away from it along and to the end of a graduated line. He is 
then told to approach the bead slowly and to mention directly 
he sees it. This proceeding is repeated twenty times with each 
observer. Every now and then the bead is withdrawn by a 
concealed arrangement, but it sometimes continues to be seen 
when it is not there (by about two-thirds of the observers). In 
this experiment the feeling of ‘‘ now-ness’”’ is artificially aroused 
in the observer, so that he does not realize that his percept 
is a revived one and the result is that he projects a vivid 
instead of a faint image; in other words, he has a true 
hallucination. 

Hallucination and illusion, then, are to be regarded as dis- 
turbances of the normal processes of ideation and perception, 
illusion being more nearly related to perception, and hallucina- 
tion to ideation. 


PSYCHOLOGY OF HALLUCINATIONS I39 


Psychology of Hallucinations and Illusions.—The physiological 
mechanism of hallucination and illusion above described is the 
same for all patients, but we have so far taken no account of the 
fact that the particular form which hallucinations and illusions 
assume varies from patient to patient. ‘Nothing could remind 
us more forcibly than this that every patient is a problem in 
himself, having a personality and individuality of his own, and 
that we have to study his individual psychology. /Unconscious 
desires are more or less the same in everybody, but the particu- 
lar form which an unconscious desire assumes in any given 
individual depends upon his particular experience of the world; 
_and hallucinations and illusions are nothing more than the ful- 
filment of unconscious wishes, in much the same way as dreams 
are—the only difference being that an insane person actually 
lives his dream. In dementia preecox, for example, the halluci- 
nations are the unconscious creation of a world in which the 
patient wishes to live; in many cases hallucinations are merely 
the crystallization of delusions; the terrifying hallucinations of 
delirium tremens usually have a phallic signification; while 
hysterical hallucinations are a compromise between conscious 
‘and unconscious wishes. These various statements will be 
better understood by the student after he has learned the pyscho- 
logical characteristics of the several mental disorders. 

Difficulty of Ideation.—On p. 43 we had occasion to remark 
that a greater effort of attention is necessary to ideation than to 
perception. Accordingly we find that ideation is difficult for 
all patients suffering from defective power of voluntary atten- 
tion. Melancholiacs, for example, often complain that they are 
unable to picture (7.e., to visualize) their dearest friends and 
relations. This is probably due to the fact that unconsciously 
they do not wish to do so. Physically this symptom is due, as 
we shall see later, to partial paralysis of volition and voluntary 
attention. Difficulty of ideation occurs also in all cases of 
imperception. 

The ideational type of the insane is difficult of investigation 
not only on account of their confused state of mind, but also 
because they are mostly unpractised in psychological intro- 
spection. The small number of satisfactory observations which 
I have made in this direction do not warrant any conclusion 
being drawn. The type appears to be as variable as in sane 
people. 


CHATTER SITL | 
DISTURBANCES OF THE ASSOCIATION OF IDEAS. 


THE association of ideas may be disturbed in one or more of 
three different ways: it may be (1) retarded, (2) accelerated or 
(3) there may be disorder of the normal ideational sequence. 

(1) Retardation of the flow of ideas may result from 
(a) partial paralysis of the cortical neurons, (6) destruction of 
many of the cortical neurons, (c) incomplete development of 
the cortical neurons or (d) more or less extensive peripheral 
(cutaneous) anesthesia. | 

(a) The cortical paralysis here referred to is that which occurs 
in melancholia. The reasons for the belief that such paralysis 
is the physical basis of melancholia are fully discussed under 
that heading. It has been determined by means of the reaction 
apparatus that association-time is increased in all states of 
depression and it is a matter of everyday experience, not only 
that melancholiacs are slow of thought, but also that physio- 
logical melancholy is inimical to successful thought. 

(b) Destruction of the cortical neurons occurs, or rather has 
already occurred, in all forms of secondary dementia, especially 
in that of general paralysis. In these cases retardation of 
thought is a pronounced symptom. It also occurs in most cases 
of organic insanity in which the destructive lesion is of wide 
extent and in association with degeneration of the cerebral 
arteries. 

(c) Incomplete development of the cortical neurons in idiocy 
and imbecility presents a clinical picture similar, so far as the 
flow of thought is concerned, to that which is presented by their 
subsequent destruction. 

(d@) When, on account of cortical disturbance, a large area of 
the surface of the organism becomes anesthetic, the process of 
ideation lacks much of its normal stimulus, the ordinary stimuli 
to thought being sensations derived from various parts of the 
body, particularly from the organs of special sensation, including 
the skin. Hence we find that, in states of exhaustion, confusion 


and stupor associated with peripheral anesthesia, thought is 
140 


ACCELERATION OF THE FLOW OF IDEAS Tar 


retarded to such an extent that it appears in many cases to be 
completely arrested. 

(2) Acceleration of the flow of ideas occurs in maniacal excite- 
ment. Increased rapidity of association is to be inferred from 
the speech of an acute maniac. When he is incoherent, the flow 
of his ideas is so rapid that it is impossible for an observer to 
trace any connection between them, but at times it becomes 
possible to discern their association. One example will suffice: 
the writer offered a cigarette to an acute maniac, who imme- 
diately remarked, “‘ Tobacco, Virginia, Virgin Queen, Elizabeth, 
my mother’’, as quickly as the words could be uttered. Such 
rapidity of association is impossible in a sane man; it is known 
as the * flight of ideas’. This tendency to rapid association in 
such patients is by no means a persistent phenomenon; it easily 
tires. 

(3) Disorder of the normal sequence of ideas is characteristic of 
all states of excitement and is dependent upon lack of attention. 
It is perfectly true that the association of ideas in these morbid 
states obeys the ordinary laws relating to the frequency, recency, 
relative position and vividness of the associated idea; but 
‘whereas, in a normal individual, irrelevant associations are 
more or less inhibited by some interest in or attention to a goal- 
idea, in maniacal states such interest or attention is wanting 
and association becomes free and disordered from lack of in- 
hibition. 

It must not be supposed that patients with fixed delusions suffer from 
disorder of the process of association so far as ideational sequence is con- 


cerned. The judgments are erroneous for other reasons which will be 
discussed in a subsequent chapter. 


DISORDERS OF MEMORY. 


Of disorders of memory there are three, respectively known 
as amnesia or loss of memory, hypermnesia or excess of memory, 
and paramnesia or falsification of memory. 

Amnesia.—There are two varieties of amnesia—(1) inability 
to retain new mental impressions (anterograde amnesia) and 
(2) inability to recall former mental impressions (retrograde 
amnesia). Anterograde amnesia may occur by itself, but retro- 
grade amnesia is always accompanied by anterograde. The 
former variety occurs to a slight degree in severe cases of 
melancholia, to a greater degree in the mental degeneration 
of senility and it is most marked in cases of anergic stupor 


I42 MIND AND ITS DISORDERS 


and, in a way, in post-epileptic states and so-called masked 
epilepsy. 

In seeking the cause of any disturbance of memory it is neces- 
sary to bear in mind the results obtained from experiments 
with the memory apparatus. It will be remembered that the. 
tendency of an idea to be subsequently recalled depends on its 
vividness, on the amount of attention paid to it, on its frequency 
of occurrence and on the prominence of its temporal and spatial 
position in any given series of ideas. 

Now in the several conditions in which there is inability to 
retain new mental impressions it is seen on examination that 
the cause of the disorder of memory varies. The disorder is 
always slight in melancholia; but, when it occurs, it is entirely 
dependent on lack of attention to mental presentations. It is 
possible that this factor also plays a part in the causation of 
the memory disturbance characteristic of old age; but here there 
is another factor which must be borne in mind, viz., that with 
an old man a new idea stands out less prominently among his 
hundreds of thousands of previous ideas than with a young man 
whose ideas have been much less numerous. The hypothesis has 
been advanced that the cortex “loses its plasticity ’’ in old age. 
This phrase I take to mean that the cortical neurons work stiffly 
and are inelastic in their action, like the old man himself. It 
may be so. 

In anergic stupor and in exhaustion states the chief factor in 
the causation of memory disturbance is more or less extensive 
peripheral anesthesia, which destroys the vividness of all per- 
cepts. In this condition attention also is wanting and the 
result is that such patients completely lose the memory of the 
greater part of their illness. 

In states of post-epileptic automatism and of masked epilepsy, 
patients are liable to perform most complex actions full of inci- 
dent and yet be unable subsequently to remember anything 
about them. I do not know of any record of a systematic 
examination of patients in these conditions, but circumstantial 
evidence goes to show that there is neither loss of sensation nor 
lack of attention. All that we are able to say is that the con- 
tent of post-epileptic consciousness is dissociated, at its onset 
and its close, from that of the normal consciousness of the 
afflicted patient. Dissociation from the previous mental con- 
tent may easily be accounted for by the loss of consciousness 
which is the essential part of an epileptic fit; but what exactly 
happens when the patient returns to his normal condition it is at 


AMNESIA 143 


present impossible to say. We shall have to discuss the matter 
more fully in connection with the splitting of consciousness. 
For the moment let us be satisfied with the recognition that, in 
accordance with the general psychological principle that every 
mental symptom is the fulfilment of an unconscious wish, 
although frequently in a disguised form, mental patients suffer 
from amnesia of a given period because they wish to forget it. 

The defective memory of imbeciles is mainly due to lack of 
attention. 

We now come to the discussion of those conditions in which 
a patient is unable to recall previous mental impressions (retro- 
grade amnesia). Such conditions occur during post-epileptic 
states, in states of exhaustion (confusional insanity), in secondary 
dementia of all kinds and in organic insanities. 

The post-epileptic states have to be again mentioned in this 
connection because account must be taken, not only of the fact 
that incidents occurring in these states are subsequently for- 
gotten, but also of the fact that during such states the patient 
forgets all about his normal life. We are here dealing with a 
variety of double personality, and it may be mentioned in this 
' connection that there are also cases of double personality which 
are certainly not epileptic. There are, also, post-epileptic states 
in which loss of memory takes place in accordance with the “ law 
of regression ”’ to be presently described. The progressive loss of 
memory characteristic of dementia is invariably in accordance 
with this law. Lastly, we must bear in mind that the normal 
tendency to forget painful situations and incidents or, at least, 
other situations and incidents which might remind us of them is 
also present in the insane, and many of their amnesie, including 
some of these above mentioned, are due to this normal mental 
characteristic. 

The law of regression of memory is but a special application 
of the law of dissolution of the nervous system, that dissolution 
takes place in the reverse order of evolution. The earliest 
functions of the nervous system to be evolved are the least 
complex, the least voluntary, the most instinctive, and these 
ultimately become the most organized. The last functions 
to be evolved, and therefore the least organized and most un- 
stable, are the most complex, the most voluntary and the least 
instinctive. Dissolution takes place in the reverse order, the 
most complex and least instinctive functions being the most 
likely and the first to become affected, and the least complex 
and most instinctive are the least likely and the last to become 


T44 MIND AND ITS DISORDERS 


affected. This law is applicable to the evolution and dissolution 
of memory. The memory of recent events goes first, that of 
remote events last; and, in general, it is found that ideas are 
forgotten before actions. In the domain of language dissolution 
takes place in the following order: proper names, common 
nouns, adjectives and verbs, and lastly interjections, this being 
the reverse order to that in which these parts of speech are 
acquired. 

Occasionally a retrograde amnesia is only for events which 
are recent in relation to a given time. This condition was ex- 
emplified in a remarkable manner by a female patient, aged 
fifty-six, who was admitted to Bethlem Hospital on November 28, 
1896, on account of an attack of insanity following head injury. 
On admission she was confused and used to nurse the pillow, 
saying that it was her newly-born son. On December 7 she 
said that this son was three weeks old, that the year was 
“ eighteen-sixty-something ’’ and that her own age was thirty- 
nine. When asked whether she remembered Queen Victoria’s 
Jubilee she remembered some public rejoicings about the year 
1850 (apparently the 1851 Exhibition). On December 9 she 
said that she was aged forty-two and her son six years; on 
December 21 that she was fifty and her son twenty; and on 
January 3, 1897, when she had practically recovered, she stated 
that she was fifty-six years old and her son twenty-six. This 
was true. The possibility of the amnesia being the fulfilment of 
an unconscious wish did not occur to me in those days. 

In advanced dementia patients remember practically none of 
the incidents of their later life, but even in this condition the 
ordinary rules of memory hold good to some extent. For 
example, any incident which makes a profound impression is 
liable to be remembered. For this reason, if for no other, it is 
not wise to promise even the most advanced dement that his 
name will be placed on the next discharge-list, in the hope that 
he will forget. Such a promise may make an impression too 
profound to allow it to be forgotten. 

The loss of memory in acute confusional insanity appears to 
be more extensive in its range than in the above conditions. 
In this state some patients forget even such thoroughly organized 
ideas as their own name, much less can they tell their where- 
abouts in space and time. The physiological explanation of 
these amnesiz is as follows: in many of the above states, especi- 
ally in anergic stupor, acute confusional insanity and advanced 
dementia, there is loss of sensation, which is at times very con- 


AMNESIA 145 


siderable. This is dependent upon damage to the cortical 
neurons (? synapses) and therefore to the ideational centres in 
which memory images are revived. Such damage is temporary 
in stupor and confusion, permanent in dementia. 

It is found that, after recovery, all cases of epilepsy (masked 
or otherwise) and of post-epileptic automatism, most cases of 
anergic stupor and some of acute confusional insanity have 
little or no remembrance of the attack. The same may be said 
of many cases of head injury and sudden organic brain lesion. 
Such events give rise to gaps in the patient’s memory, mental 
scotomata or lacunz which have been called partial amnesiz. In 
most of these conditions this is easily explained by the fact 
that sensation, and therefore consciousness, is either abolished 
oratavery lowebb. On the other hand no satisfactory explana- 
tion has yet been offered for the loss of memory in post-epileptic 
automatism or masked epilepsy. To say that dissociation of 
the mental state takes place at its onset and close is, after all, 
merely a restatement of the facts in more obscure terminology. 
The condition appears to be rather a cramping of the memory 
than a complete amnesia, for the patient can often perform 
complicated feats which necessitate the retention of memory of 
some sort, a kind of subconscious memory. Another circum- 
stance for which no satisfactory explanation has yet been offered 
is that, in many of these states, the patient loses memory of 
events which happened immediately (twenty minutes or so) 
before the cerebral shock occurred. 

It will be observed that some of the phenomena described 
under the heading of imperception may also be regarded as 
instances of partial amnesia. 

There are many experiments which may be made to determine 
a patient’s memory for recent events. He may be asked to say 
what time of day it is,* what day of the week, day of the month, 
what month and what year. He may be asked what he had for 
his last meal. Marie employs the following test: the patient 
is given three pieces of paper of different sizes and is told, for 
example, to fold the large piece into three and to put it under 
his pillow, to fold the medium-sized piece into four and give it 
to the nurse and to tear up the small piece and throw it out of 
the window. Another ordeal devised by Marie is to tell the 
patient to go and tap three times on the window-pane, to open 


* Most healthy people can estimate the time of day to within a few 
minutes, especially if they have seen a clock or met with some incident 
jndicating the time within the past two hours. 

10 


40 MIND AND ITS DISORDERS 


and close a given door, to return to his seat, make a military 
salute and sit down. Such trials as these usually bring out any 
defect of recent memory on the part of the patient. 

As a test for the revival of memory-images a patient may 
be asked to enumerate a dozen birds, animals or flowers. If 
he fails to do so, his capability of reviving memory-images 
is deficient; if he repeats himself, there is some loss of recent 
memory. 

The late Dr. Mercier drew attention to what he believed to 
be another variety of loss of memory, which he called, paradoxi- 
cally, ‘‘loss of memory for future events”. He referred to 
patients who forget appointments, forget that they have to 
write an urgent letter, to catch a train or to lock the safe before 
leaving the office. Clinically it is important to recognize this 
symptom, the forgetting of resolutions, because it is liable to 
occur during the early stages of any form of mental disorder; 
but psychologically it is nothing more than an exaggeration of 
the normal function of forgetting (g.v. p. 50), the exaggeration 
being due to the fact that the repressing forces are weakened 
in all forms of mental disorder, and indeed in nearly every 
disease, whether mental or physical. A resolution is for- 
gotten because of an unconscious wish that it should not be 
carried out. 

Hypermnesia.—In many cases of mania, especially of chronic 
mania, a condition is met with in which the patient has remark- 
able exaltation of memory. He can tell with perfect accuracy 
what happened to him or what he was doing at any given date 
since the beginning of his illness; or he can instantly recall the 
name of any person he has seen, perhaps only once, and that 
years ago, but since the beginning of his illness. This pheno- 
menon is doubtless related to the general hyperesthesia of these 
patients. Stimuli of moderate intensity arouse in them more 
vivid percepts than in normal people and are hence more liable 
to attract their attention. : 

Partial hypermnesia is frequently observed in cases of im- 
becility. . In these cases there is no general hypermnesia, but 
there is an exaltation of memory for ideas or incidents of a par- 
ticular nature, which arouse their interest and attention. ° Other 
ideas and incidents have no interest for them, and for these their 
memory is exceedingly bad. Some havea remarkable memory 
for dates. A patient at Prestwich Asylum could enumerate all 
the occasions on which any given medical officer of the institution 
had played tennis. 


PARAMNESIA 147 


Paramnesia.—We have already seen that an essential part of 
any act of memory is the emotional tone of familiarity. Now 
if this emotional tone should arise during an act of perception, 
the total process is one of recognition; and should the feeling 
arise during an act of ideation or conception, the total process 
is one of memory. In the insane, and occasionally in the sane, 
this mood of familiarity may arise without any justification; for 
example, (a) the mood of familiarity may arise in entirely new 
surroundings, with the result that the person so affected thinks 
he has “been there before”’; he recognizes his surroundings: 
(>) the mood arises in association with the idea, for example, of a 
visit from a friend, with the result that the person remembers the 
visit, which has not occurred. These abnormal psychic processes 
are known as paramnesia. Curiously enough, the latter process, 
which is the more complex of the two, has been called “ simple 
paramnesia ’’ and the former has been called “‘ paramnesia by 
identification ’’. Such nomenclature is confusing. The two pro- 
cesses respectively should be spoken of as * illusions of recogni- 
tion ” and “illusions of memory ’’. In thus naming them there is 
no misuse of the word “illusion ’’; for paramnesia is practically 
a misrepresentation which originates in sensations, sensations 
derived from those muscular and arterial changes which underlie 
the mood of familiarity. 

Illusions of recognition and memory are liable to occur in any 
form of insanity in which the emotions become dominant but 
are most common in the variety of mental disorder usually 
associated with multiple neuritis, the ‘‘ polyneuritic psychosis.” 


CHAPTERS: 
DISORDERS OF THE EMOTIONS. 


In this section we have to consider morbid modifications of 
the emotional reaction to percepts and ideas of situations and 
incidents in the outside world. In the insane such emotional 
reaction may be excessive or deficient, the cause of the excess 
or defect differing in the various diseases with which we have 
to deal. 

Persistent states of depression and hilarity are common in 
many forms of mental disorder, especially in maniacal-depressive 
insanity, and it is better to defer their consideration until this 
disease is discussed. Until recently no explanation was forth- 
coming why general paralysis has such a remarkable tendency to 
induce a persistent emotional state of happiness and exaltation. 

In those conditions which are dependent upon progressive 
deterioration of the nervous system, such as general paralysis, 
alcoholic insanity and epileptic insanity, emotional reaction is 
excessive, the most unimpressive word or gesture often sufficing 
to induce an attack of weeping, laughter or anger. The same 
may be said of maniacal excitement. Paranoiacs and patients 
suffering from hallucinations are especially liable to outbursts of 
anger and other forms of emotion. Imbecility, too, is a condition 
in which excessive emotional reaction may be observed. We 
have also to consider those patients who suffer from morbid fears. 

Deficient emotional reaction, on the other hand, characterizes 
confusional and stuporose states, myxcedema, cretinism, senility 
and all extreme forms of secondary dementia. 


EXCESS OF EMOTIONAL REACTION. 


The doctrine is now well established that dissolution of the 
nervous system takes place in reverse order to its evolution, and 
it has been demonstrated that the last motor tract to develop 
in the history of the vertebrate nervous system is the pyramidal 
tract. It is in accordance with this doctrine that the first motor 


tract to suffer in such progressive degenerations of the nervous 
148 


EMOTIONAL DEFECT I49 


system as general paralysis, alcoholic insanity and epileptic 
insanity is the pyramidal tract; and the consequence is that 
in these diseases motor impulses tend more and more to be 
transmitted by way of the more primitive motor tracts vid the 
red nuclei. 

Now these are the tracts which normally subserve the function 
of emotional reaction and so it happens that patients suffering 
from the above diseases react emotionally to unimpressive 
stimuli whose main outlet is by way of emotion-arousing tracts, 
the volitional tracts being unavailable. 

In states of maniacal excitement the tendency to excessive 
emotional reaction is dependent upon a different set of condi- 
tions. In the chapter on maniacal-depressive insanity I shall 
show reason for the belief that mania is a state in which the 
neurons contain some irritating body or bodies; the neurons are 
consequently in a permanent state of excitability. The result of 
this constant state of tension of the neurons in maniacal states 
is that minimal stimuli provoke nervous discharge and, in the 
case of motor neurons, induce muscular contraction. 

The application of this principle to the emotionality of maniacal 
‘patients is as follows: a perceptual or ideational process occurs 
in one of the association-areas of the cortex; all the neurons 
in functional communication with this area, especially the cortico- 
rubral neurons, are discharged; in other words, discharge over- 
flows into the emotional regions of the nervous system. 

The emotional outbursts of paranoiacs and of patients suffer- 
ing from hallucinations may be looked upon as being due to 
excessive perception, in contrast to those forms of diminution 
of emotional reaction which are due to imperception (vide infra). 
The laughing or weeping of a patient, who has just experienced 
an illusion or hallucination, takes place because he has perceived 
something (which is not there); he has suffered from excess of 
perception. 

Similarly paranoiacs suffer from excess of perception; their 
association of ideas is excessive and they see hidden meanings in 
the most trivial incidents, A passer-by in the street blows his 
nose and the paranoiac perceives the handkerchief as the cloak of 
a sneer or smile; the result is the emotional reaction we call anger. 

The excessive emotional reaction characteristic of the imbecile 
is to be accounted for as follows: The nervous system of the 
imbecile and therefore his pyramidal system, which even in a 
normal child is developed late, are incomplete in development. 
Accordingly the pristine cortico-rubral system is uncontrolled, 


I50 MIND AND ITS DISORDERS 


the volitional pyramidal system being unavailable to take over 
its usual share of the functions of the pristine system. It is 
this uncontrolled action of the pristine motor system which 
must be held responsible for the excessive emotional reaction of 
the imbecile. 

Morbid fears arise in quite another way. They are really 
symptomatic of unconscious desires. When a person experiences 
a desire which, for some reason or other, he does not wish to feel, 
perhaps because he thinks it wrong or wicked, he represses it 
into his unconscious, and it becomes replaced in consciousness by 
its opposite, namely fear. He then suffers from morbid fear of 
any situation which tends to remind him of his unconscious 
aspiration, even symbolically. In some cases, on the other hand, 
the fear is traceable to some situation, consciously forgotten but 
remembered by the unconscious, to which the patient did not 
react emotionally at the time; so that, as it would appear, there 
is a certain amount of emotion (fear) floating about loose, so to 
speak, which tends to attach itself to any situation resembling 
the original, even remotely. Examples of both these mechanisms 
will be given in due course. 


DEFICIENCY OF THE EMOTIONAL REACTION. 


If you tell a person a good joke, there are three possible 
reasons for his not laughing at it: (1) He does not hear it, (2) he 
does not “see”’ it or (3) he is preoccupied. Such are the three 
causes of deficient emotional reaction among the insane. 

In confused and stuporose states the patient suffers from anes- 
thesia of characteristic distribution. In such cases perception 
is deficient because sensations are not satisfactorily served up 
to the ideational centres and emotional reaction is absent for the 
same reason that a deaf man does not laugh when you tell him a 
joke. It is also to be observed that in these patients there is a 
further reason for the loss of emotional feeling in that the muscular 
sense is defective; the patient would not fully experience an 
emotional feeling, therefore, even if slight motor reaction should 
occur. 

Emotional defect may be due to partial or complete imper- 
ception. This occurs to a greater or less extent in cases of 
secondary dementia, arteriosclerosis, myxoedema, cretinism and 
idiocy. In all these conditions there is corresponding deficiency 
of emotional reaction, for the same reason that some people 
cannot “ see’ a joke. 


EMOTIONAL DEFECT i hei 


In some cases of this kind emotional reaction occurs, but its 
character is inappropriate to the occasion. For example, it 
sometimes happens that an advanced dement laughs on being 
told that a relative, once dear to him, is dead. Those familiar 
with psycho-analysis will discern a further explanation of this 
phenomenon. 

Absence or deficiency of emotional reaction occurs in severe 
cases of melancholia, not only of pleasurable, but also of painful 
emotional reactions. Such patients experience no pleasure when 
they think of their home, wife and family; they commonly tell 
us that they have lost all affection for their friends; and when it 
becomes our painful duty to inform a melancholiac of the death 
of his nearest and dearest relative he commonly remarks “ I 
don’t seem to feel it’. 

The cause of this lack of emotional reaction is not far to seek. 
As I shall point out in a subsequent chapter, the greater part 
of the muscular system of melancholiacs is rigidly fixed owing 
to partial paralysis of cortical neurons, and it is on this account 
that the motor changes essential to emotional reaction cannot 
take place. 

Katatoniac stupor also is characterized by muscular rigidity. 
This rigidity differs from that of melancholia in that it affects 
the whole of the muscular system uniformly, whereas the rigidity 
of melancholia affects mainly the musculature of the spinal 
column and the large proximal joints. The practical point 
is this: that in katatoniac stupor there is motor fixation as in 
melancholia and it is on account of this fixation that there is 
deficiency of emotional reaction. 

Later we shall see reason for the belief that the deficiency of 
emotional reaction in other forms of dementia preecox is apparent 
rather than real and that the reaction is only repressed by these 
patients. 

The conclusions arrived at in this section may be summarized 
as follows: Excess or defect of emotional reaction may be 
dependent upon excess or defect of sensation or upon excess 
or defect of perception. Excess of emotional reaction may also 
depend upon an abnormal tendency of motor impulses to be 
transmitted via the pristine emotion-arousing nervous system. 
Defect of emotional reaction may further be due to fixation of 
the emotion-arousing musculature. 


CHAPTERS: 
ABNORMALITIES OF ACTION (DISORDERS OF CONDUCT). 


DISORDERS OF VOLITION. 


THE insane are liable to perform all sorts of abnormal acts as the 
result of insane delusions. Of such a nature are the setting of 
traps in order to ensnare supposed persecutors, the barricading 
of doors to obstruct the ingress of supposed enemies, the plugging 
of keyholes to prevent poisonous gases being instilled into the 
room, the wearing of concealed armour and the more ostenta- 
tious wearing of fantastic dress, tinsel crowns and self-conferred 
medals. I have known a patient, suffering from the delusions 
that she was infectious, eat such refuse from her food as nut- 
shells and fish-bones lest these should convey infection to another 
person. All such voluntary acts are hable to degenerate in time 
into automatic acts; they are then known as insane habits. 
More important still are the drug habits (alcohol, morphia, 
cocaine etc.), which will be considered in their proper place. 

Paralysis of volition, 7.e., paralysis of the capacity of forming 
a clear idea of a movement to be performed, is known as apraxia. 
This is paralysis of the “ highest motor level”’ of Dr. Hughlings 
Jackson, which is situated in the left prefrontal lobe, not paralysis 
of the middle level whose cell-stations are in the Rolandic motor 
areas. Apraxia consists of an inability to perform certain 
actions, although the person suffering from it has no paralysis 
of movement or sensation of the affected parts. Ifa patient be 
told to raise his arm, to point at an object or to shut a book he 
makes movements which are quite inappropriate. If he be 
shown a candle, given a box of matches and told to light the 
candle, he appears to have no idea of the movements required 
for such an action. 

There are two varieties of apraxia—agnostic and ideomotor. 

Agnostic apraxia is dependent on imperception or agnosia (vide 
p. 124). In this form the patient is unable to perform a given 


action because he does not recognize the nature of the article 
152 


APRAXIA 153 


which he is required to use for such an action. For example, a 
man is shown a pencil but does not recognize it as a pencil; he 
does not know what it is because his perception is defective. If 
now he is told to write something with the pencil his movements 
are confused; he makes no attempt to write, because he does not 
grasp the fundamental idea that the article in his hand is an 
implement for writing. 

In the other form, ideomotor apraxia, to keep to the same 
example, the patient knows that he holds a pencil in his hand 
and knows what it is for; yet when he is told to use it he fumbles 
with it and appears to have no idea of the movement of writing. 

It is a good test for motor apraxia to get the patient to measure 
some object with a tape-measure. In order to detect slighter 
degrees of apraxia it is a useful test to get him to perform a 
given action without all the articles required for such action. 
For example, give him a button-hook and tell him to go through 
the movement of fastening a button with it; in other words, 
to pretend to fasten a button. The resulting movements in a 
case of apraxia are nothing like the correct movements although 
the patient may be able to button his own boots. Asa still more 

'severe test he may be asked to show how he would count out 
change (money), but without any coins; he will perhaps go 
through a series of movements as if he were dealing cards. If 
you hold out your hand to him as if to receive the coins he will 
perhaps shake hands with you. 

Ideational inertia is sometimes observed in apraxia, as in imper- 
ception. The following excellent example has been recorded by 
Dr. S. A. K. Wilson. The patient was given a match, which he 
recognized as such. He was then asked “ How would you use 
it ?”’ He replied “I would strike it, like that’ (imitating the 
movement). He was then shown a pencil, which he also recog- 
nized. On being asked how he would use it, he replied “ I would 
strike it, like that ’’ (again performing the movement of striking 
a match). 

A patient of mine was shown a lens. He called it an eye- 
glass and put it to his eye. He was now shown a penknife; 
he called it a penknife but put it to his eye as if to look through 
it. He was next shown a pencil; he recognized it as a pencil, 
but put it to his eye, like the other objects (perseveration). 

Apraxia is a very characteristic symptom of chronic cortical 
atrophy from senility, arteriosclerosis or syphilitic endarteritis. 
It is met with in post-epileptic states and during the recovery 
of general paralytics from apoplectiform attacks. It is also seen 


154 MIND AND ITS DISORDERS 


in states of exhaustion, in acute and subacute alcoholism and 
in severe cases of the polyneuritic psychosis. 

Apraxia is a good illustration of the principle that dissolution 
is a reversal of evolution. In every child, and indeed in every 
adult, there is a certain amount of difficulty or disability in per- 
forming a new, unpractised voluntary action; and apraxia is 
a reversion to this condition, but it differs in that there is dis- 
ability in the performance of well-practised voluntary actions. 
When my housemaid takes upon herself to place my tennis- 
racquet in its press she inserts it at the side instead of at the 
end of the press: this is an example of apraxia during evolution. 

In functional and organic disorders of the middle motor level 
(Rolandic area) there is paralysis of voluntary movement al- 
though the patient has a clear idea of the movement he wishes 
to perform, the motor ideational centre in the left prefrontal lobe 
being intact. Such paralysis of voluntary movement occurs as 
the result of coarse brain disease such as thrombosis, embolism, 
hemorrhage, abscess, tumour etc., destroying the excitable 
motor areas of the cortex. 

Such lesions are usually of fairly rapid onset and cause local 
paralysis. In general paralysis, on the other hand, there is a 
slow, insidious, diffuse, chronic, progressive cortical lesion gradu- 
ally destroying the cortical neurons, especially those subserving 
the function of voluntary movement and there is corresponding 
progressive paralysis of volition. 

Among the functional mental disorders (biogenetic psychoses) 
the most typical example of paralysis of volition is melancholia. 
In severe cases of this disease the patient stands motionless and 
silent and no voluntary movement takes place for weeks or 
months together. This paralysis affects the muscles of the spinal 
column and of the large proximal joints most, the muscles of the 
hands and feet being affected to a very small degree or not at all. 
In milder cases the patient merely complains that he is “ unable 
to do things’’. As in most cerebral palsies, a certain amount of 
rigidity accompanies this paralysis. 

There is a form of katatoniac stupor in which a somewhat 
similar muscular condition obtains. The patient stands motion- 
less and silent, just like a melancholiac; but the rigidity is even 
more marked and its distribution is uniform, so that the joints of 
the hands and feet are as rigid as those of the shoulders, hips 
and spinal column. This rigidity sometimes involves the face 
muscles (Snautz- krampf). 

Anergic stupor is another condition in which there is paralysis 


DISORDERS OF INSTINCT | 155 


of volitional movement. In this state the patient suffers from 
peripheral anesthesia of the kind already described, so that 
ingoing stimuli are usually insufficient to arouse the idea of 
movement. It will be shown later that functional motor 
paralysis also obtains in this disorder (ultimately of unconscious 
origin). 

The lack of volitional movement in dementia is largely due to 
partial anesthesia, ingoing stimuli being insufficient to induce 
the movement-idea. 

Partial or complete anesthesia is also to be held responsible, 
to some extent, for the paralysis of volitional activity occurring 
in states of intoxication due to alcohol, chloroform, chloral, 
morphine and allied drugs. 

The paralysis in fatigue is due, as we have already seen, to 
the accumulation of certain products of metabolism in muscle 
substance. 

Increase of volitional activity is commonly known as “ pressure 
of activity’. In maniacal states this occurs mostly at the large 
proximal joints (shoulders, hips and joints of the spinal column) 
and it is probably due, as will afterwards appear, to irritating 
toxins within the cortical neurons. In agitated melancholia 
it occurs mostly at the small peripheral joints and is probably 
due to irritating toxins circulating in the nutritive fluids which 
bathe the cortical neurons. Similar pressure of activity occurs 
in some cases of subacute alcoholism. 


DISORDERS OF INSTINCT. 


It was pointed out in the first part of this manual that in- 
stinctive action is closely allied to, in fact the same thing as, 
emotional reaction. The considerations of the last chapter 
therefore pave the way for the study of the disorders of instinct. 
These are excess and defect; and there are certain other disorders, 
which may be called “‘ erroneous instincts ”’. 

The instincts are increased in the early stages of general 
paralysis, alcoholic insanity, epileptic insanity and cerebral 
arteriopathy; and they are diminished in the later stages of these 
diseases as well as in confusional and stuporose states, secondary 
dementia, myxcedema and cretinism. They are also diminished 
in melancholia. 

Exaltation of the instinets occurs most typically in general 
paralysis, in which the primitive motor system becomes dominant 
on account of degeneration of the pyramidal tracts or regression 


156 MIND AND ITS DISORDERS 


of volition. The symptom would be explained psychologically 
by saying that primitive acts of the unconscious become domi- 
nant because they are less controlled or uncontrolled by the 
conscious mind. The eating instinct is increased from the first, 
and the patient gourmandizes, not because he is hungry but 
because he is greedy. An increased sexual instinct often gets 
him into trouble with the police authorities in the early stage 
of his disease. The instinct of acquisitiveness shows itself in 
kleptomania and the tendency to buy hundreds of superfluous 
and unnecessary articles. In the terminal stages of the disease 
some of the infantile instincts again become dominant: the 
patient instinctively clasps objects placed in his hand and carries 
them to his mouth, and perhaps the very last movement to 
disappear is reflex sucking when an object is placed in contact 
with his lips; but perhaps these are reflexes rather than instincts. 

An increase of instinctive movements is also to be noted in the 
epileptic and alcoholic insanities, but usually to a smaller degree 
than in general paralysis. Of such a nature are the brawling, 
screaming and aimless activity of alcoholic mania and intoxica- 
tion. The same symptoms are to be observed in some states of 
maniacal excitement, not perhaps with the same uniformity; 
but there is the tendency to collect, the exaltation of the sexual 
instinct and of the instinct to eat something, not necessarily 
food, for some excited patients, especially those suffering from 
katatoniac excitement, are often quite pleased to eat earth or 
the grass of the field. 

What may be regarded as an increase of instinctive activity 
also arises in certain obsessive states. In these, actions may 
arise as the result of imperative ideas. For example, a patient 
has a feeling that his hands are dirty; he looks at them and sees 
that they are perfectly clean, but this has no inhibitory action 
on the original feeling that they are dirty and he feels compelled 
to go and wash them. A fruitless struggle against such an 
absurd compulsion goes on in the patient’s mind and he has no 
peace until his hands are washed. Such activities invariably 
have some symbolic meaning. 

The morbid impulses are clearly allied to such states as the 
above and we have already seen that all impulses are instinctive. 
An irresistible impulse to act in a certain way occurs to a patient, 
perhaps to strike his children, and the act is performed without 
reflection and often without resistance. The patient recognizes 
his own lack of inhibitory power and may ask others to prevent 
him from carrying out the act. 


INSANE CONDUCT 157 


The psychological mechanism of all these impulses is the same 
as that of morbid fears mentioned in the last chapter. Irresis- 
tible hand-washing, for example, is usually symbolic of a desire 
to have a cleaner mind or to wash off the stain of past misdeeds 
committed by the hands; and the impulse to strike and perhaps 
to kill one’s own children is an attempt by the unconscious to 
fulfil an unconscious desire, the reason for which varies in dif- 
ferent patients and can only be discovered by psycho-analytic 
investigation. 

Deficiency of instinctive action occurs most typically in melan- 
choliacs. These patients not only lose the primitive instinct of 
self-preservation; they even develop the idea of self-destruction, 
they refuse food, the instinct of sociability disappears and the 
sexual instinct is so far lost that melancholiacs not infrequently 
believe they are impotent. This is sometimes traceable to un- 
recognized homosexuality. 

In dementia, including that of general paralysis, instinctive 
action is diminished. First there is regression of volition, then 
regression of instinct. The instincts of locomotion and of vocal- 
ization are lost. Advanced dements do not play games and they 
have no ambitions. The instinct of acquisitiveness, which has 
probably, in the earlier stages of their disease, been strikingly 
demonstrated by a tendency to collect rubbish, has now entirely 
disappeared. At meal-times they have to be led to the table 
and, when there, the attendants frequently have to see to it that 
they eat the food which is placed before them—not because they 
actively refuse it, but because it has no interest for them. 

Many remarkable disturbances of instinctive action, erroneous 
instincts, occur in dementia precox, especially in the katatoniac 
variety. Negativism, for example, is a fairly constant symptom 
of katatoniac stupor: it may also occur in states of exhaustion. 
It is a curious condition in which any suggestion made to the 
patient at once arouses the counter-suggestion. If a katatoniac 
be told to step forward, he steps backward; if he be asked to 
show his tongue, he compresses his lips; if he be told to go to the 
dinner-table, he walks away from it. This symptom must not 
be taken for perversity: the patient cannot help it, it is instinct 
gone astray. Psycho-analytically it is perhaps a “ resistance ”’. 

Stereotypy is a symptom seen mostly in dementia precox, but 
also in confusional states. This isa condition in which the patient 
constantly repeats the same movements for long periods together; 
he will repeat to-and-fro or rotatory movements with his arms; 
he may walk up and down the same patch of ground for hours 


158 MIND AND ITS DISORDERS 


together, or in circles or figures of eight. The so-called man- 
nerisms of dementia precox are closely allied to stereotypy: 
one patient will keep an arm stiff, another will always hold his 
legs straight when in the act of sitting down or rising from a 
seat, another will drop on all-fours several times a day. These 
patients are quite unable to give any reason for such antics; 
they are merely instincts gone astray. Of course, these actions 
are not so meaningless as they would appear to be; there is an 
unconscious reason for every one of them, though extremely 
difficult to ascertain in this particular class of patient. 

Automatic obedience is another symptom seen mostly in 
dementia przcox, but also occasionally in some states of con- 
fusion. A patient showing this symptom will, if touched under 
the chin, raise his head and keep it raised for a minute or so; 
if touched on the top of the head, he will flex his neck again; 
if gently pushed from behind, he will take a few steps forward, 
and soon. A special form of automatic obedience is eehopraxia. 
A patient showing this symptom will perform any antic which 
another person takes the trouble to perform in front of him: if 
you raise your arm, he will raise his; if you protrude your tongue, 
he will protrude his; if you jump, so will he. 

By constant repetition many of the above instinctive acts of 
the insane become, in the course of time, automatic. Klepto- 
mania, masturbation, wet and dirty habits, touching objects 
(folie de toucher), the antics of the katatoniac and even the 
tearing of clothes may all become habitual. In a few patients 
(usually hypochondriacal melancholiacs) even the refusal of food 
degenerates into a habit. I have known several patients who, 
rather than take food in the usual way, would three times a day 
regularly for months at the bidding of the doctor pass an ceso- 
phageal tube on themselves and pour down a feed of milk and 
eggs or broth. 


DISORDERS OF SPEECH. 


These occur in parallel with the disorders of action in other 
departments. In stupor, melancholia, dementia, fatigue etc., in 
which there is paralysis of voluntary action, there is paralysis 
of speech and the patient is silent or nearly so. In the motor 
excitement of mania there is noisiness and garrulity. Corre- 
sponding to stereotypy we have verbigeration in which the 
patient repeats the same sentence hundreds of times in the course 
of a day. Mannerism of speech shows itself in stilted modes of 


INSANE WRITING 159 


expression. Corresponding to echopraxia we have echolalia in 
which the patient repeats everything that is said to him, with or 
without change of pronoun. For example, the doctor asks “* How 
are you to-day ?”’ and the patient replies “‘ How am I to-day °”’ 
and corresponding to the antics we have in the domain of speech 
a symptom for which I have proposed the name pseudolalia. 
Patients presenting this symptom apparently pretend to speak; 
but in reality they utter a series of meaningless sounds, such 
as “‘Camalaba, dink-a-di-dink, goosey-goosey-wadlum’’. The 
reduplicative tendency of this mode of speech suggests that it 
is of instinctive origin. 

When a patient’s speech is of such a nature that another 
person is unable to follow his line of thought, it is said to be 
incoherent. Incoherence results from two causes: (1) The 
patient is so lacking in voluntary attention that any chance 
percept, such as the striking of a clock or a glimpse of the doctor’s 
tie-pin, by arousing his instinctive attention diverts the current 
of his thoughts; (2) the patient’s flow of thought is too rapid 
to allow all the connecting links to be expressed in words; such 
a patient is not incoherent to himself. 

It will be observed that incoherence is not necessarily a sign 
of insanity. If you stand by a person talking through a tele- 
phone, he is probably incoherent to you because the connecting 
links of the conversation are missing; but he is not therefore to 
be regarded as insane. 

The writing of the insane is disordered in exactly the same 
way as their speech. Garrulous, voluble patients, who are 
sometimes said to be suffering from “‘logorrhcea”’, often write 
many sheets of foolscap daily (‘‘ graphorrhcea’’). Patients 
suffering from stupor, severe melancholia, advanced dementia 
or advanced general paralysis do not write at all. Incoherence 
occurs in the writing of the insane, as it does in their speech, 
and for similar reasons. Katatoniacs perform all sorts of tricks 
with their writing, just as they do in other departments of volun- 
tary action. Their style is apt to be stilted and circumlocutory. 
They form their letters with unnecessary care or perhaps have 
some fantastic alphabet of their own (pseudographia). Pseudo- 
graphia may also occur as a form of apraxia (Fig. 22). Ideational 
inertia may also be occasionally detected in the writing of an 
apraxic patient (Fig. 23). 

The writing of the general paralytic is characterized by the 
omission or repetition of letters, syllables and words. This 
symptom possibly depends on some functional disturbance of 


160 MIND AND ITS DISORDERS 


the visual-perception centre, since similar mistakes are to be 
observed when the patient reads aloud; he omits some words 
and inserts others which are not to be seen on the page before 
him. | 

Writing is a recently acquired attainment in the history of 
the human race and individual and is therefore one of the earliest 
attainments to become disordered in all acute dissolutions of the 
nervous system. Accordingly we find that one of the earliest 


Fic. 22.—APRAXIC PSEUDOGRAPHIA. 


Envelope addressed by an arteriopathic dement to his wife. 


symptoms of an acute attack of insanity is deterioration of 
the patient’s calligraphy and of the art of expressing himself in 
writing. 

Reaction-Time.—Many investigations have been made upon 
the reaction-times of patients suffering from mental disease and 
it has been found that their reaction-time for all mental pro- 
cesses 1S invariably longer than natural. The greatest respect 
is due to those who have carried out these laborious investiga- 


APRAXIC WRITING 


MIND AND. ITS DISORDERS 


DISORDERS OF ATTENTION 163 


tions, but their results must be regarded as valueless. Every- 
body who has worked in a psychological laboratory knows that 
it takes months of practice to become a competent subject for 
psychological experiment; and it is for this reason that the 


We obs Lino thee sh pene - 


Send ne avo Sree cough dre he 
Fan kink of pusrcele you mar be abe 
ls gut “Than, URE Siecene 


FIG. 24.—SENILE WRITING. 


results obtained from patients, who have little or no such previous 
experience, must all be discounted, apart from the fact that 
the reaction experiment per se throws no light upon mental 
processes. 


DISORDERS OF ATTENTION. 


Since attention is a special form of action our study of dis- 
ordered action has prepared the way for the study of disordered 
attention. 

Inasmuch as a strong will is the essential characteristic of 
a strong and stable personality, excessive voluntary action in 
a strict sense can never be a symptom of mental disorder; and 
therefore there can never be such a condition as excess of volun- 
tary attention. If, on the other hand, it is contended that such 
a condition may occur, it cannot be a symptom of mental dis- 
order. , 

Defect of voluntary attention (aprosexia) occurs in exactly the 
same conditions as defect of volition in general. These are, as 
we have already seen, states of exhaustion, melancholia and all 
forms of stupor, imbecility, and gross lesions of the cerebral 
cortex in the neighbourhood of and especially anterior to the 
motor areas. Defect of voluntary attention is noticeable from 
the first and is steadily progressive in such diseases as general 
paralysis, cerebral arteriopathy and other forms of dementia. 


164 MIND AND ITS DISORDERS 


Just as we found, in the previous section, that deterioration 
of volition is accompanied in most cases by exaltation of in- 
stinct; so we find that defect of voluntary attention is, in the 
first instance and in most cases, accompanied by exaltation of 
instinetive attention (hyperprosexia). In states of excitement 
occurring in the infection and exhaustion psychoses the patients 
are incapable of voluntary sustained attention to the doctor’s 
remarks, but the clink of his keys or a glimpse of his watch-chain 
suffices momentarily to arouse instinctive attention. One of the 
chief difficulties in educating an imbecile is his incapacity for 
sustained voluntary attention; his attention must be aroused 
instinctively and the possibility of chance percepts reduced to 
a minimum, for even a fly crawling across the window-pane 
suffices to divert the current of his thoughts, by claiming his 
instinctive attention. Instinctive attention is excessive in the 
earlier stages of all mental disorders in which voluntary attention 
is deficient, with the exception of melancholia and some forms 
of stupor. 

The importance of “‘ interest ’’ in determining which percepts 
and ideas will stimulate instinctive attention is well illustrated 
in patients suffering from delusions. Delusions are usually of 
such a nature that the object of delusion invariably claims the 
patient’s instinctive attention. This state of affairs is seen in 
a characteristic form in paranoia, in which the patient’s whole 
attention is centred on some particular fad or fancy. 

Diminution of instinctive attention occurs in melancholia and 
in all forms of advanced dementia and stupor. These include 
anergic stupor, katatoniac stupor and the stupor associated 
with some states of exhaustion. 

Reflex attention appears to be increased in some patients and 
diminished in others; but it has not yet been ascertained with 
which mental disorders the increase and diminution are respec- 
tively associated. 

Maniacal and some other excited patients are easily startled 
and many neurotic persons also complain of this symptom. 


CHable kay i: 
ERRONEOUS JUDGMENTS (DELUSIONS). 


DELUSIONS are not only full of interest from a medico-psycho- 
logical standpoint, but they are all-important from a legal point 
of view. Many abnormal states of depression and excitement 
do not appeal to the legal mind as states of insanity; but, if it 
can be shown that a patient suffers from an absurd delusion, 
a court of law is readily convinced of his insanity. 

Delusions are not necessarily a sign of insanity. We all have 
our delusions, but we are not all insane. Some people believe 
that thirteen is an unlucky number, others believe that this is 
not so. One of these two classes of people is suffering from 
a delusion; but, whichever class this is, they are not insane. 
Similarly the natives of Central Africa hold many judgments 
as true which are regarded by civilized people as delusions, but 
these Africans are not therefore to be regarded as insane. 
Children are not insane when they believe that their dolls are 
hungry or suffer from an illness, but such ideas in an adult would 
amount to insanity. 

It thus becomes necessary to make a distinction between sane 
and insane delusions. An insane delusion is usually defined as 
a judgment which cannot be accepted by people of the same class, 
education, race and period of life as the person who expresses it. 

It has been objected that, according to this definition, every 
man who has some new and great truth to communicate to the 
world is to be regarded as insane. This is not the case, how- 
ever; for every such man has achieved his particular discovery 
by prolonged study of the special branch to which it belongs. 
In other words, he is of vastly superior education, in that par- 
ticular branch, to the rest of mankind. When Darwin pro- 
mulgated his doctrine of the descent of man he was regarded 
as little short of insane by the proletariat; but those biologists 
who had more nearly approached his standard of education 
and were therefore most competent to judge were the first to 
accept his conclusions. 


165 


166 MIND AND ITS DISORDERS 


It would serve no useful purpose to give a complete list of all 
the delusions that have been encountered among the insane, 
even if it were possible to make such a compilation; but the 
student will gain some idea of the commonest delusions from the 
following list: 


A patient may believe 


That something dreadful is going to happen to himself or 
his relatives. 

That he is going to be hanged or burnt. 

That nobody cares any more for him. 

That he is deserted by God and eternally damned. 

That he has committed “ the unpardonable sin ”’. 

That he has committed a great crime. 

That he will lose all control of himself. 

That he has a hole in his head or in his back. 

That his brain has gone. 

That his throat is blocked up. 

That his bowels are obstructed. 

That his legs are paralyzed or made of glass. 

That he is made of wood. 

That he is an animal—a sheep, a wolf or a bird. 

That he is only a few inches high and weighs but a few 
ounces. 

That he is miles high and weighs tons. 

That he is God or Christ. 

That he is the rightful heir to the throne. 

That he is the King, or the Emperor of China. 

That he is engaged to a great lady. 

That he is a millionaire or that he is ruined. 

That he is persecuted by means of electricity, hypnotism 
or ““ soreerism ’’. 

That there is a systematized conspiracy against him, extend- 
ing over the whole of the civilized world. 

That he is unworthy to live. 

That he will never die. 

That he is dead. 

That he has “ cataracts’ in his head. 

That the asylum is a Jesuit establishment. 

That the other patients are of the opposite sex. 

That he is a musician or poet. 

That he can raise the dead. 

That he is the strongest man in the world. 


INSANE DELUSIONS 167 


This list, which could probably be multiplied a thousandfold, 
accentuates the fact that every individual, including every 
mental patient, has his own peculiar mode of thought, which 
must obviously depend upon his own particular experience of 
life, differing from that of every other person. 

However absurd such delusions may be, no amount of argu- 
ment will serve to convince the sufferer of their unreasonable- 
ness. The old proverb that— 


‘A man convinced against his will 
Is of the same opinion still,” 


is more true of the insane than of any other class of the com- 
munity. 

The delusions of the insane have hitherto been regarded as of 
little diagnostic value; but, to an understanding psychologist, 
they throw much light upon the mode of thought of the patient's 
unconscious mind. Delusions are analogous to or, in a way, 
identical with dreams, the difference being that a deluded person 
lives his dream. A dream is the fulfilment of an unconscious 
wish, usually in distorted form. So is a delusion, and it is at 
least a matter of psychological interest to determine how any 
particular delusion has arisen. The physician who makes a 
point of ascertaining this as often as possible will find that 
he gains thereby a clearer insight into his cases and a more 
powerful grasp of the subject of insanity in general. Further, 
the physician should take pains to ascertain all the delusions 
from which his patient is suffering, if only to avoid hurting his 
feelings by chance remarks having apparent reference to his . 
fancies. 

The causes of a delusion are of two kinds, predisposing and 
exciting. The predisposing cause is the patient’s mood, usually 
determined by the unconscious mind. If he is in a state of 
depression and misery, he is prepared to believe that he is to 
undergo the most horrible and excruciating tortures that can be 
devised. Ifa poor man is ina state of happiness, joy and elation 
never before experienced, he is ready to believe that he is a 
person of influence and importance and that he is possessed of 
untold wealth: “ the wish is father to the thought’. If a person 
is in a constant state of suspicion, he sees hidden meanings in 
commonplace incidents and is prepared to believe that everyone 
is against him and is persecuting him. 

In many cases it is impossible to discover any other than this 
emotional predisposing cause of delusion, but exciting causes are 


168 MIND AND ITS DISORDERS 


also at work in the majority of cases. Of these the most frequent 
are hallucinations. This will be readily understood, for if a 
person is not to believe the evidence of his senses, what is he to 
believe 2? If he hears voices over his head, what more natural 
conclusion than that there are people in the room above? If 
God appears to him in the heavens, it is not very unreasonable 
for him to conclude that he is ‘‘ the elect of God ’’; and if his 
food tastes bitter, it is fairly rational for him to believe that 
it has been drugged. Of course, such hallucinations are un- 
consciously created by the patient, just as his delusions are. 

Many patients arrive at an erroneous judgment by exaggerating 
the ordinary symptoms of their disease. Melancholiacs always 
suffer from severe constipation and many conclude from this 
symptom that their bowels are permanently obstructed, especi- 
ally if they have the “ epigastric sensation ’’ at the same time. 
The chief physical basis of melancholia is a slight double hemi- 
plegia of functional origin; hence many patients develop the 
notion that their legs are permanently paralyzed. As we have 
already seen, melancholiacs lose the function of emotional reaction 
as well as the power of voluntary movement (popularly known as 
“the will’’); hence they conclude that they have lost their soul 
and are deserted by God, that they must have committed the 
unpardonable sin and that they are eternally damned. 

Memory defects are responsible for a certain number of delu- 
sions, especially erroneous ideas of time and place. The follow- 
ing case is probably an example of a delusion taking its origin 
in a temporary lapse of memory: A gentleman was returning 
from Paris to London. Shortly before he arrived at Calais he 
fell into an epileptic state (so-called masked epilepsy), but con- 
tinued his journey. When half-way across the Channel, he 
jumped overboard. The only person who saw him do so was a 
middle-aged lady, who straightway had an attack of “‘ hysterics ”’ 
and did not tell the crew what she had seen until it was too late. 
The patient was a strong swimmer, was picked up by another 
boat and ultimately taken to Chartham Asylum. Now he has 
no memory of his remarkable experience, nor does he remember 
leaving France; consequently he believes that he is still on the 
Continent and that the various institutions in which he has been 
lodged since his return to these shores are English kidnapping 
establishments in the middle of France. 

The normal tendency to the “ unity of ideation ’’ plays an im- 
portant rdle in the origin of delusions, as may be shown by the 
following examples: A patient was looking down the trap of a 


——————— 


INSIGHT 169 


drain in the garden when he heard a voice (in hallucination) ; 
he thought that the voice proceeded from the drain and there- 
fore that there was somebody down there. Another patient was 
watching the movements of a blackbird a few yards from him, 
when he heard in hallucination the remark “‘ You d——d fool !”’ 
He concluded that it was the bird that had insulted him. A 
patient suffering from the epigastric sensation had hallucinations 
of hearing; the conclusion was that the voice proceeded from his 
abdomen and that he had a devil in his inside. A woman was 
in the habit of seeing faces in the fire. One day, just after she 
had seen the outline of her husband’s face in this way, she was 
taking meat out of the oven when she heard his voice in hallu- 
cination. Her conclusion was that the meat was human flesh 
and that she had cooked her husband. 

From these examples it will be seen that the erroneous judg- 
ments of the insane are not so illogical as they appear at first 
sight. That their reasoning is not in accord with the strict laws 
of logic is obvious; but there would be no advantage in classifying 
delusions according to the nature of the particular logical fallacies 
of which the patient has been guilty. 

As with the man in the street, there is no logical fallacy of 
which the insane may not be guilty at times; but there is one 
fallacy which is essential to a patient suffering from a delusion, 
viz., the ignoratio vel ignorantia elenchi, ignorance of the main 
question. The main question with patients suffering from de- 
lusions is that they are insane. If they were to realize that 
they are suffering from delusion, the delusion would tfso facto 
cease to exist. The majority of the insane fail to recognize 
that they are suffering from mental disorder, but a few have a 
certain amount of “ insight ’’ into their condition. 


INSIGHT. 


It is rare for a patient to have any insight into his own mental 
condition at the onset of a first attack of insanity; but a large 
number of patients are capable of appreciating the nature of 
their malady when it is explained to them or when they find 
themselves placed under care in an institution for the insane. 
Such patients are said to have “ insight ”’. 

We have just seen that all who suffer from insane delusions 
lack insight; and from the investigation of patients we find that 
the converse usually holds good, that those patients who lack 
insight almost invariably suffer from an insane delusion, and that 
those who have insight do not. Accordingly we find insight most 


I70 MIND AND ITS DISORDERS 


characteristically in cases of intermittent and periodic insanity, 
other states associated with depression, the compulsion neurosis, 
neurasthenia, acute and chronic intoxications and some of the 
milder forms of imbecility, provided always that the patient has 
no delusions and that the mental disturbance is not so severe as 
to prevent his thinking at all about the matter. 

Insight is characteristically absent in all forms of stupor 
and confusion, secondary dementia, epileptic insanity, general 
paralysis, fever delirium, collapse delirium and the severer forms 
of idiocy; but it will always be found that the amount of insight 
depends upon (a) the patient’s capability of coherent thought 
and (d) the presence or absence of delusion. 


DISORDERS OF SENTIMENT. 


Inasmuch as sentiment is one of the latest acquirements of 
the human race, it is not to be wondered at that it is very easily 
and frequently disordered, both in the sane and in the insane. 

Since a sentiment is the voluntary formation of a judgment 
as to the presence or absence of truth in a statement, beauty in 
an object or morality in an action, it follows that sentiment 
is deficient in all those conditions where volition is deficient, 
where the volitional system is more or less in abeyance, either 
from functional disorder such as melancholia and stupor or 
from organic degeneration of the pyramidal system as in general 
paralysis. 

Max Nordau regarded some of the works of Rossetti, Burne- 
Jones, Wagner, Swinburne, Tolstoi, Ibsen, Gautier, Zola and 
many Others as productions sufficiently anti-zsthetic to justify 
him in stigmatizing these great men as degenerates. There are 
not many who agree with him and even Max Nordau himself 
stops short of suggesting that such men should have been placed 
under treatment for mental disorder. 

I have never heard of a patient being sent to an asylum merely 
because his artistic productions betrayed a lack of esthetic 
sentiment or of an unscientific person being confined on account 
of his deficiency of intellectual sentiment; but if a patient’s 
conduct is immoral and therefore antisocial, the law may demand 
that he be placed under restraint. If he be regarded by the 
law as irresponsible for his immoral actions, the restraint is in 
an asylum for the insane; if responsible, in gaol. 

As we have already seen, morality is nothing more or less than 
an innate desire to comply with the customs and desires of one’s 
fellows. This instinct is the last to be acquired by the human 


DISORDERS OF SENTIMENT Lak 


race, as compared with such universal animal instincts as those 
of nutrition, self-preservation and sex. Morality has also been 
defined as the foregoing of immediate pleasure for the purpose 
of gaining enhanced benefits in the future; in other words, it is 
the voluntary suppression, for the purpose of future gain (or 
for the avoidance of future pain), of the tendency to immediate 
instinctive action. Immorality then is the letting loose of 
instinctive action owing to defective volition. Immoral acts are 
therefore liable to occur in all progressive degenerations of the 
nervous system, because the more recently evolved volitional 
motor system (the pyramidal tract) suffers dissolution at an 
earlier date than the unconscious instinctive (cortico-rubral) 
motor system. 

Accordingly we find immoral acts occurring in early general 
paralysis, chronic alcoholism, epilepsy, acute alcoholic intoxica- 
tion, in the earlier stages of cerebral arteriopathy and in other 
forms of dementia. We often read of a highly respectable 
citizen, previously of unimpeachable character, being sentenced 
to a term of hard labour at the age of sixty-five for some act of 
immorality. His arteries are degenerate, his volitional nervous 
system begins to fail him and his personal instincts are therefore 
uncontrolled. The saddest thing of all is that no amount of 
expert evidence will convince the judge that this is a consequence 
of the arterial degeneration of old age. 

In idiots and imbeciles voluntary control is never completely 
developed; if their pyramidal system develops, it is a weakly 
functioning apparatus. In some cases (moral imbeciles) im- 
morality is almost the only symptom of mental disorder. Prob- 
ably the difference between these patients and habitual criminals 
is only one of degree. 

entiment is deficient in all states associated with anesthesia 
and imperception for the same reason that emotional reaction 
is diminished in such conditions (see p. 150). It is accordingly 
deficient in organic disease of the ideational areas, in cases of 
confusion and stupor, in secondary dementia, senility, myx- 
cedema, cretinism and idiocy. 

On the other hand, patients suffering from acute mania and 
paranoia are always ready to pass judgment upon the sayings 
and doings of others, as every medical officer of an asylum well 
knows; he hears many home-truths during the course of his 
morning round. 

In many cases of obsessional insanity (folie de doute) there is 
marked exaggeration of sentiment. Such patients have to be 


172 MIND AND ITS DISORDERS 


reassured again and again that such and such a statement is true 
or false, as the case may be, or that they themselves have made 
their meaning clear and not made some false statement. They 
have to be constantly reassured that they have not “ done the 
wrong thing ’’; and whether an object is beautiful or ugly may 
be to them a positive source of worry. 

It will be observed that all these cases of exaggerated senti- 
ment are associated on the one hand with hypersensitiveness or 
on the other hand with motor excitement. 

I have already hinted, in the section dealing with erroneous 
judgments, that a patient’s belief in them is often rational. 
Nevertheless, instinctive belief plays an important role in a 
patient’s conviction of the truth of his delusions. . 


CHANGED PERSONALITIES. 


When we attempt to form a concept of the personality of an 
individual suffering from an attack of mental disorder, a concept 
of his “‘ ego ’’, there is no doubt in our own minds that the very 
fact of his being insane changes that personality. Much more 
must we suppose that, from the point of view of the patient, 
there is a vast change in his personality, were it possible for him 
to examine it. 

Occasionally we come across cases in which the personality 
is so far changed that the patient becomes an entirely different 
individual. His very identity is changed, as also his ordinary 
habits and instincts; his voice and manner of speech, even his 
calligraphy becomes that of another person. He does not 
answer to his own name, this too having altered; and if he be 
questioned about the person bearing that name, either he never 
knew such a person or his knowledge of him and his habits may be 
of the foggiest nature. Some such patients pass through three 
or more different identities; indeed a few years ago an account 
appeared in the Journal of Mental Science of a patient who had 
aS many as eleven personalities at different times, and I have 
had a patient with eight. 

Such changed personalities are usually revealed by hypnotism, 
but quite commonly they appear as the effect of disease alone. 
It should also be added that hypnotism may be responsible for 
their creation. In some cases the subject or patient is merely 
converted or restored to her (they are usually women) former 
self at an earlier age, as in the case of retrograde amnesia men- 
tioned on p. 144; in other cases the change is more complete. 
In any case the new personality is to be regarded as a permanent 


SEX AND STATION 173 


subconscious state which is merely revealed by effacement of 
the existing personality, the subconscious state becoming mani- 
fest by temporary obliteration of phenomenal consciousness. A 
submerged part of consciousness (subconsciousness) is allowed to 
come to the surface. Dr. Frederick Myers’ iceberg analogy may 
help to make my meaning clear. 

If the whole of the visible portion of an iceberg were removed, 
one-tenth of the remainder would rise above the surface and 
present an entirely new aspect: and if this newly visible part 
were removed, one-tenth of the remainder would as before rise 
above the surface and present another new aspect. Nevertheless, 
the submerged nine-tenths would, if they were visible, give the 
appearance of a base for a superstructure. In some instances, 
however, the removal of the visible portion would so upset the 
balance of the whole that the mass would make an extensive 
revolution and its new appearance have no similarity whatsoever 
to the original. 

So it is when phenomenal consciousness is abolished. Insome 
patients one can discern a basis for the superstructure; in others 
the subconscious part of mentation which becomes manifest 
presents no resemblance to the original personality. 


SEX AND STATION. 


Nobody can go round an asylum without being struck by the 
difference between the insanity of men and women. The greater 
tendency of women to motor reaction is strikingly demonstrated 
both in excited and depressed states. Maniacal women are 
more noisy, more excitable and give much more trouble than 
maniacal men; and the motor symptoms of melancholia are 
always more easily observed on the female than on the male side; 
the women are more liable to be stuporose and, when agitation 
occurs, more agitated. 

In accordance with the greater tendency of women to fatigue 
we find that the insanity of exhaustion occurs more frequently 
in them; but it must not be forgotten that they are especially 
liable to such physiological processes as childbirth and menstrua- 
tion, which are apt to lead to exhaustion and may be unduly 
prolonged or associated with profuse hemorrhage. 

The anesthesia which I have described as being especially 
associated with mental disorder is more frequently found and 
is usually more extensive in women than in men. 

There is also an interesting sexual difference in the nature of 
delusions. Egoistic man develops the delusion that his bowels 


I74 MIND AND ITS DISORDERS 


are obstructed, that he is dead, that he is going to prison or that 
there is a huge conspiracy against him. An unmarried woman 
is apt to develop similar delusions. But the altruistic married 
woman's care is all for her husband and children. She hears her 
children’s cries as they are being burned or otherwise tortured, 
she fears that she has injured others, that she has not been a good 
wife and mother or that she may never again be able to tend her 
husband and children. 

Insanity occurs rather more frequently in men than in women. 
This is especially the case with general paralysis for reasons which 
will subsequently be considered. 

At the present time there are no statistics of the relative 
frequency of insanity in the lower and the educated classes, 
because it is difficult to ascertain the proportion which the 
educated classes bear to the general population. A visit, how- 
ever, to a number of county and private asylums leaves no 
doubt in the mind of the most casual observer that the motor 
reaction of county patients is greater than that of private patients. 
The excited patients of the former class are more garrulous and 
noisy than those of the latter. This, of course, does not betoken 
a difference in the character of the mental disorder of the two 
classes; the lower classes are naturally more garrulous and noisy 
than the educated, but this characteristic restlessness of insane 
patients of the lower classes is especially liable to lead to fatigue 
and exhaustion and thus to prejudice their chances of recovery. 


THE COMPREHENSIVENESS OF MENTAL DISORDER. 


At the end of the section on normal mentation it was stated 
that the various faculties of mind are interdependent. It follows 
as a corollary that no faculty of mind can be disordered without 
the others being also affected, at least to a slight extent. 

For example, a person suffering from disorder of perception 
cannot be regarded as fully capable of reasoning about objects 
of perception in his environment. Further, disorder of percep- 
tion is liable to affect the conduct in some measure. Again, take 
the case of a patient suffering from some insane delusion. This 
is bound to affect his conduct in many ways, and it is a matter 
of experience that such a delusion tends to colour the patient’s 
memory of incidents which occurred long before the delusion 
existed. Loss of memory per se warps a patient’s judgment 
concerning things forgotten, and even concerning things asso- 
ciated with things forgotten. 


COMPREHENSIVENESS OF MENTAL DISORDER 1s 


We cannot regard any “ part ’”’ of mind as being affected alone. 
Mind is not a “ thing ’”’ to be divided into “‘ parts’: mentation 
is a process dependent on the functioning of the whole cortex 
cerebri and any disorder of this function interferes with the 
process of mentation as a whole. 

Nevertheless, we are bound to admit that disorder of a given 
mental faculty in one direction does not necessarily imply 
disorder of that faculty in all directions. A man may be in- 
capable of recognizing some objects but quite capable of recog- 
nizing others; he may be able to remember incidents of one kind 
but not those of another; and his conduct may be quite abnormal 
in some situations but perfectly normal in all others. In like 
manner, a patient’s judgment may be warped in one direction 
only. It does not follow that, because he is suffering from some 
insane delusion, his judgment on all other matters is erroneous. 
He may fancy that he is the prophet Jeremiah and yet be quite 
capable of transacting an important piece of business; he may 
think that the earth has gone out of its course and yet make 
a reasonable will or he may believe that he is the victim of 
worldwide conspiracies but at the same time be capable of 
solving the most abstruse mathematical problems. 


GHAPTIE Rey iE 
PSYCHO-ANALYSIS. 


PsYCHO-ANALYSIS, to which frequent reference has already been 
made, is best described here because we shall have to refer to it 
again when describing the various mental disorders, although 
its proper place is perhaps at the end of the book, because it is 
a method of treatment. 

Although psycho-analysis is commonly regarded as being a 
recent growth, it is the outcome of more than thirty years of 
laborious scientific investigation by Professor Freud of Vienna, 
who is undoubtedly the greatest living psychologist, in my 
opinion the greatest psychologist the world has known, and 
still contributes much to our knowledge of the science. 

Essentially psycho-analysis is his method of investigating the 
unconscious mind of a person, usually of a patient, so that he 
can discern the unconscious origin of his symptoms and thus 
dispel them. It is mainly applicable to the neuroses, psycho- 
neuroses and, in smaller degree, the biogenetic psychoses; but it 
will be seen later that symptoms arising in even the organic 
insanities can be explained on _ psycho-analytic principles. 
Moreover, psycho-analytic principles must ultimately be taken 
into account by general physicians, clergymen, teachers, 
criminologists, sociologists and all those who are concerned 
with the study of human thought and conduct. We venture to 
hope that these will always bear in mind that they owe this 
knowledge to medical science and that any attempt to divorce 
modern psychology from medicine must prove fatal to their 
cause. It appears also to be necessary to utter a warning that 
those who intend to study this subject should take it seriously . 
and not dabble in it. 

Psycho-analysis has met with much opposition, not only on 
account of its novelty and the universal tendency to accept 
traditional rather than experiential knowledge, but also on 
account of several misapprehensions. Being a mode of psycho- 
therapy, it is supposed to be something like hypnotism, in which 


the physician imposes his will on the patient, whereas nothing 
176 


OPPOSITIONSTO SPs YCHO-ANALYSIS Las 


is farther from the truth, for the psycho-analyst plays rather 
a minor réle in the treatment. As already stated, psycho- 
analysis is a method of investigating the unconscious mind of 
a patient, and the only person who has access to this is the 
patient himself. It is therefore the patient who does all the 
talking while the physician tells him absolutely nothing; the 
function of the analyst is merely to instruct the patient in the 
technique and to keep him to it. Psycho-analysis is the only 
branch of medicine in which the doctor so scrupulously, strictly, 
and even strenuously, refrains from telling the patient anything 
about himself or giving instructions as to his mode of conduct 
and manner of life. : 

Another objection is that the psycho-analyst assumes the role 
of a priest in the confessional and that any beneficial results of 
the treatment are due to the patient having unburdened his 
mind and shared his sorrows with another. It is perfectly true 
that an essential point in the technique is that the patient should 
tell the doctor everything that comes into his mind; but the 
reason of this is not that he must confess it to the doctor, but 
that he should acknowledge to himself thoughts and desires 
which he has hitherto failed to recognize. 

The factors, however, which have aroused the most hostile 
criticism are that Freud and his school claim that psycho-sexual 
functions play the most important rdéle in the causation of the 
neuroses and, worse, that psycho-sexual activities can be traced 
back into the early years of childhood. 

We deal with the latter objection first because it is based on 
a misapprehension. Freud agrees with us all that the child has 
no conscious knowledge of sexual activities, but he does designate 
as sexual any activities of the child which would be regarded by 
everybody as sexual if they occurred in an adult. One of my 
patients began unmistakable acts of masturbation when she was 
eight months old and continued them until at least her eighth 
year; but during the whole time it is certain that she attached 
to them no sexual valuation. Yet it is justifiable to regard them 
-as sexual; the tendency to masturbate cannot possibly be ascribed 
to any other instinct. The child is now thirteen years of age 
and fairly normal. I had hoped that the tendency would have 
no permanent effect on her; but unfortunately she has a foolish 
mother who should never have been a mother, and the patient 
has at times shown signs of nervousness. 

The strenuous opposition to the view that psycho-sexual 


trends are intimately related to the mental disorder is primarily 
12 


178 MIND AND ITS DISORDERS 


due to sentiment, the general taboo of sexual topics and perhaps 
an unwillingness to admit that we have hitherto been so foolish 
as to allow such feelings to blind our eyes to reality. Long 
before psycho-analysis, doctors used to prescribe marriage for 
hysterical girls, without knowing why; yet they would not allow 
themselves to trace their opinion to its source, probably because 
they thought that it would not pay to have their names asso- 
ciated with matters of sex. In bygone times gynecologists and 
syphilographers were regarded askance and the older physicians 
used to advise their protégés to eschew such specialisms. 

Of all human activities, thoughts and conversations, none is 
so much banned as the sexual, and this raises the question why 
the sexual instinct in particular should be a very special object 
of taboo. In seeking an answer to the question the first thought 
which occurs to us is that a racial taboo must comply with—nay 
more, its origin must be traced to—the wishes of the majority of 
the units composing the race. We are therefore driven to seek 
the origin of a racial taboo in the individual. 

In the next chapter we shall consider numerous sexual per- 
versions :—homosexuality, auto-erotism, sadism, masochism, 
fetichism and many others. Such perversions are not rare; they 
are common. Indeed Dr. Havelock Ellis, who is a great autho- 
rity on such matters, estimates that 5 per cent. of the male 
and ro per cent. of the female population are consciously homo- 
sexual. This being but one perversion among a dozen or more, 
it seems permissible to conclude that at least 25 per cent. of the 
population, even at a moderate estimate, have some consciously 
sexual perversion. 

Now consider the fact that psycho-analytical investigation 
invariably discovers some unrecognized and therefore unconscious 
sexual perversion, and we are driven to the conclusion that 
nobody is normal sexually. Most people naturally resent such 
an intolerable notion and would stoutly deny that their sexual 
instinct is abnormal. They would refuse to admit it even to 
themselves, yet it would appear that somewhere deep down in 
their minds their perversion receives recognition, and it is this 
which causes every individual to have an instinctive aversion 
from sexual topics; it is this which is responsible for the racial 
ban which has in these latter days been extended to psycho- 
analysis. 

To some of the cardinal principles of psycho-analysis reference 
has already been made in earlier chapters and now they need 
only be mentioned again. 


THE UNCONSCIOUS 179 


Psychical Determinism.—tThe first is that mental processes are 
‘ never fortuitous. No thought, no action, no dream, no act of 
memory or of forgetting, no slip of the pen or tongue, no ap- 
parently accidental mental event ever occurs by chance. There 
are always reasons for them, viz., the circumstances of the 
moment plus the whole of the person’s past experience of life. 
Moreover, on the occasion of any mental event, no other could 
have occurred at that moment; that thought or action and no 
other was bound to occur. 

The Unconscious.—We have to recognize the existence in each 
one of us of an unconscious mind of which we are quite unaware. 
It contains all those thoughts, memories, instincts and desires 
which we refuse to admit to ourselves and, as the saying is, have 
“put out of our minds’’. Really they are pushed deeper into 
the mind. It also contains percepts, which have not been con- _ 
sciously recognized, innate trends which have never met with an 
opportunity for recognition—for example, the maternal instinct 
in unmarried women—and wishes which have never been allowed 
to enter consciousness, which have never been conscious, such as 
desire for the parent of the opposite sex (CEdipus-complex). 

Inasmuch as the content of the unconscious is, for the most 
part, the psychical material which has been banished from the 
conscious on account of its lack of harmony with conscious 
thought, it follows that the wishes of the unconscious are the 
exact opposite of conscious wishes. 

Our conscious aims are those of morality, altruism, honesty, 
truth and virtue; but deep down in the unconscious of us all 
are animal tendencies to licentiousness, egoism, robbery, deceit 
and vice, however much we deny the fact. The conscious tends 
to morality, the unconscious to immorality; but before we 
discuss this basis for intrapsychic conflict, let us consider the 
word “‘immorality’’. It has a very wide meaning, yet it in- 
variably has a sexual connotation. Why ? 

The reason is not far to seek. It is quite legitimate in a draw- 
ing-room to talk of murder, theft and fraud; of topics relating 
to the instincts of self-preservation and nutrition; but of rape, 
infidelity and the sexual instinct—never! That is immorality 
par excellence ; sexual matters are more repressed than all others 
and it therefore follows that the content of the unconscious is 
mainly sexual. This conclusion is directly verified by psycho- 
analytical investigations. 

In an earlier chapter it was explained that ideas are grouped 
into constellations (so to speak). For example, any idea relating 


180 MIND AND ITS DISORDERS 


to the girl to whom a youth is engaged belongs to his constella- 
tion of love ideas, all thoughts bearing on one’s necessity or 
desire for attending social functions belong to the constellation 
of society ideas, and so forth; but there are also unconscious 
constellations of ideas. These are called complexes. | 

Complexes constitute the greater part of the unconscious, 
but it is not to be supposed that their repression into the un- 
conscious does away with them for ever. Both conscious and 
unconscious constellations urge the individual to do some par- 
ticular thing; the love constellation constantly urges a person 
to meet his mate, the society constellation urges him to attend 
social functions and, in lke manner, a complex is constantly 
striving to express itself in action. 

Yet the conscious or subconscious (“‘ preconscious ’’ in Freudian 
terminology) repression of a complex prevents it from obtaining 
expression in an undisguised form. This continuance of the 
original repression has been called by Freud “ the censure ”’ or, 
by his American translators, “the censor’’. The translation 
is rather apt in that it points to an analogy with the Censor of 
letters during war time; disallowed information must be given 
in disguise so that he cannot recognize its meaning and allows it 
to pass; but it is necessary to state that there is no implication 
that a personal imp sits somewhere on the cortical membranes 
to fulfil this function, because some critics, including a well-known 
psychologist (now deceased), have applied this interpretation to 
the notion of the intrapsychic censor. A physiological term for 
the function would be inhibition. 

Simply stated, the facts are that complexes constantly strive 
for recognition in the face of opposition; and they invariably 
succeed in one way or another by means of disguise. 

A complex may assert itself vi@ sublimation, replacement 
reaction or symptom; also, as we have already seen, in dreams. 
For example, let us take a maternal complex in an unmarried 
woman and a homosexual complex in a man. 

Sublimation is the diversion of the trends of a complex into 
useful, social, moral and ethical directions. In the above ex- 
amples the maternal complex may be diverted into attendance 
at a créche, interest in societies for infant welfare or taking up 
the nursing or teaching profession. A homosexual complex in 
a man might be sublimated into an interest in boys’ clubs, 
Sunday-schools for men or the Y.M.C.A., or, again, taking up the 
profession of schoolmaster or choirmaster. The latter, by the way, 
sometimes prove dangerous and lead the victim into temptation. 


REPLACEMENTS AND REACTIONS I81r 


Replacement is somewhat similar to sublimation, but replace- 
ments subserve no useful or ethical function. I‘or example, it 
sometimes happens that the maternal instinct in a grown woman 
is displayed in an interest in dolls and that a male homosexual 
wears corsets without knowing why he likes to do so. 

Reactions are not direct outlets for complexes, they are con- 
scious activities the very contrary of what the unconscious 
desires; yet it would appear that this reversed kind of recogni- 
tion of a complex serves to satisfy itin many cases. For example, 
some homosexuals are sexual voués devoted to sensual and 
licentious practices with members of the opposite sex, yet they 
never marry. Similarly, people who have repressed a desire 
to steal, which was evident in childhood, become scrupulously 
honest and invariably pay every bill “‘ on the nail ”’. 

These are all more or less normal ways of satisfying a complex, 
but their methods are not always so direct and obvious as in the 
examples given. All three may appear in symbolic guise. For 
example, the homosexual complex may gratify itself by a habit 
of striking trees, posts and other phallic objects or poking at 
them with the walking-stick or umbrella (also phallic) when 
the subject goes for a walk, the bringing together of two phallic 
objects symbolizing homosexuality. A patient of mine, whose 
homosexuality became patent during unconscious fugues, fol- 
lowing a shell explosion, burial and subsequent disinterment by 
another shell, dreamed that he broke his pipe (symbolizing the 
penis) and next day actually snapped it in two between his 
fingers, to his chagrin, and to all appearances, unintentionally. 
In the dream he also lost a little white ivory spot (a trade mark) 
from the mouthpiece; this symbolized semen. Those who are 
familiar with psycho-analysis will here recognize a castration 
dream and an action symbolizing self-castration. 

Many will wonder why on earth the experience of this patient 
should arouse his latent homosexuality. The explanation is not 
far to seek if one cares to think symbolically; for a shell is a 
long, penetrating, explosive thing, in short—phallic. After the 
experience, his usual dream was of running away from a shell 
which was chasing him, and dreams are invariably the fulfilment 
of an unconscious wish. 

Perhaps one of the best examples of sublimation in symbolic 
guise is that of the feces complex. Babies are much more 
interested in their excrement than is usually supposed; many 
examine it and play with it and more would do so if opportunity 
occurred. Later they like to play with mud pies, then sand, 


182 MIND AND ITS DISORDERS 


then putty or plasticine. This interest is not lost in adult life, 
it is sublimated into an interest in money, which—in psycho- 
analytic experience—we discover to be frequently associated 
with feeces. Financial expressions often supply evidence of this 
association :—we have a deposit or current account on a bank and 
money is said to be either hard or fluid. There are also such 
slang expressions as “‘ filthy lucre ’’, ‘‘ So-and-so stinks of money ” 
or he is “‘ constipated’’, meaning that he is disinclined to part 
with or that he sézcks to his wealth. A patient of mine dreamed 
that she had passed feeces into her bed and that the sheet became 
‘““water-marked like a bank-note’’. Another patient, a mil- 
lionaire, had been excessively mean and constipated all his life. 
He suffered from piles (another suggestive expression by the 
way) and some clever proctologist had cured his piles and con- 
stipation by two injections of something. He became immedi- 
ately so generous, thriftless and extravagant that he was con- 
sidered to be insane. Indeed it was for this symptom alone 
that I was consulted. And this is just what we find:—that 
constipated people are always anxious respecting the expenditure 
of money, while those whose bowels are open regularly do not 
worry about their financial affairs. It will not escape the reader 
that constipation in an apparently normal person is the fulfil- 
ment of an unconscious wish to retain feces. The evidence is 
overwhelming and it must not be supposed that even a tenth 
part of it has been given here; but it is because symbolism in 
general is so unconvincing that this particular example has been 
rather fully discussed. 

Should a complex fail to be expressed in any of the above 
ways, it becomes manifest as a neurotic or psychotic symptom. 
In some cases it appears as a somatic manifestation, as in hysteri- 
cal motor and sensory disturbances (conversion); in a second 
class the affect which belongs to the complex becomes transferred 
to some related but less repugnant conscious idea, which then 
becomes a source of worry to the patient (substitution), as in 
the compulsion neurosis; and, in a third class, the complex un- 
acknowledged by the patient is ascribed to other people (pro- 
jection), asin paranoia. These, which are merely a few examples 
of the way in which a complex may reveal itself in symptomatic 
guise, will be explained in more detail, and others will be men- 
tioned in subsequent chapters as the various symptoms come 
under discussion. 

Last, but by no means least, we have to recognize that infantile 
mental processes form the permanent basis for all later develop- 


INFANTILE PSYCHO-SEXUAL TRENDS 183 


ment. Mental energy, like physical energy, is indestructible. 
Thoughts, memories and desires may be repressed into the un- 
conscious, but they are never lost or destroyed. An instance 
of this has already been considered in the sublimation of a childish 
interest in feeces into an adult interest in money; and, since 
Freud has demonstrated that the foundation of sexual life is laid 
during the infantile period, we shall have to examine the develop- 
ment of the sexual instinct. 

Psycho-sexual Trends.—It appears to be necessary to repeat 
insistently that psycho-analysts do not ascribe to the child any 
knowledge of the sexual meaning of those of its activities which 
to the adult mind have a sexual signification. 

At the time of birth, the child passes out of its soft warm 
comfortable bath through the most excruciating torture of 
universal compression (with its head and face squeezed out of 
shape) into a cold hard world where its first experience is that 
of suffocation and none too delicate manipulation by relative 
giants. 

After this initial experience of fear, probably the greatest terror 
a person ever suffers, any pleasure that it happens to find must 
surely be greatly enhanced by contrast. Very early in life it 
discovers that it has certain powers within itself, viz., those of 
micturition, defecation and sucking, all of which give pleasure. 
The three primary pleasure zones are then the neck of the bladder, 
the anus and the mouth; and there is plenty of evidence to show 
that these acquire in later life a sexual valuation which is usually 
unconscious, but sometimes—and not very rarely—conscious. 
Infantile sucking has indeed been compared with coitus, and 
the subsequent flushing of the face, followed by sleep, with a 
sexual orgasm. 

It is not, however, merely for such a superficial reason as this 
that sexual significance is attached to the oral phase of develop- 
ment, as Freud has called it, during the first year of life; but 
because we find during psycho-analysis that innumerable sexual 
associations and characterological peculiarities trace back to this 
period, wherein we find the beginnings of auto-erotism or self- 
love. Most children like to rub various parts of their own bodies, 
and some start masturbation at this time. The inner surface 
of the thighs and the breasts are found to give pleasure on 
manipulation mostly in female infants. 

The phase of anal erotism follows that of oral erotism. The 
child obtains physical pleasure in evacuating the bowels not 
consciously sexual in the first instance, but found on subsequent 


184 MIND AND ITS DISORDERS 


psycho-analysis to have sexual associations in our character- 
ological investigations. There is a second stage to this period, 
when a certain amount of repression of this function is imposed 
on the child by its nurse or mother, which may lead to a desire 
to retain faeces and to the subsequent gratification of passing 
a constipated bolus. The anal phase may be said to last during 
the second and third year. Then follows the phallie stage, in 
which the penis plays an important réle in the mind of the infant, 
and this, curiously enough, occurs in both sexes—a fact which 
renders the subsequent psychical development of the female 
much more complex than that of the male. For example, we 
find deep down in the unconscious mind of every female the 
notion that she has become female by losing the penis (castration 
complex). It is extraordinary, too, how frequently we find’a 
castration complex in the male, owing apparently to threats 
during early life of having the penis cut off. On the other 
hand, this castration idea is sometimes self-imposed by the . 
patient in consequence of the feeling of guilt induced by early 
masturbation. 

The fourth period, which lasts roughly during the fourth and 
fifth years, has been called by Freud the genital phase, during 
which the sexual organs achieve their more natural significations. 
Then follows a stage of repression, lasting until puberty, which 
Freud has called the “‘latent period’’. From puberty to adoles- 
cence, however, we find that the same order of development is 
carried out all over again, viz., the oral, anal, phallic and genital, 
not so consciously as during the infantile period; but analysis 
of the various activities occurring at this time of life proves them 
to be founded upon the psycho-sexual significance of identically 
the same eroto-genic zones. The tuck-shop, cigarettes and 
chocolates afford occasion for manifestations of the oral activity 
at this time, the anal phase is manifested chiefly by certain 
sadistic and masochistic tendencies and activities, and the 
pnallic phase by a recrudescence of masturbation, which is 
clitoric in the female, not vaginal. 

Freud has recognized, and everybody with psycho-analytical 
experience has confirmed, that in addition to these main eroto- 
genic zones (the mouth, anus, neck of the bladder, penis, clitoris, 
inner surface of the thighs and breasts) many other organs of 
the body contribute to psycho-sexual development. In short 
the child passes through numerous sexual perversions in minia- 
ture during its development, and this fact has caused Freud to 
designate the normal child as being “‘ polymorph-perverse”’. A 


PSYCHO-SEXUAL DEVELOPMENT 185 


normal sexual instinct is ultimately achieved by repression of 
the perversions in favour of the primary genital zone. 

About the fourth year the hitherto auto-erotic child begins to 
find an external object of love, firstly in the person of the mother 
or her surrogate or the nurse, later in other members of the child’s 
own family. Since psycho-analytical explorations have revealed 
the fact that all love has a sexual basis, we are not misusing 
terms when we point out that a girl’s love for her mother is 
homosexual. Curiously enough, we often find that a boy’s love 
for his mother is also homosexual at this age, especially in those 
not infrequent cases in which he supposes his mother to be 
anatomically fashioned like himself. 

Asa rule, however, when the conduct of both parents is normal, 
we find that, by the tenth year, the boy loves his mother and 
the girl her father the more (beginning of conscious hetero- 
sexuality). 

During the early “ teens ’’ incest barriers are set up and a love 
object is sought outside the family. In boys this is usually a 
girl, but in most girls the love object is quite commonly a school- 
mistress (replacing the mother) or some other girl until the later 
“ teens ’’ when normal heterosexual trends develop. 

Lastly, it has to be noted that, in the unmarried female, the 
clitoris is the most sensitive sexual organ, and that marriage 
normally has the effect of transferring this sensitiveness to the 
vagina. 

Now psycho-analysis has revealed that what is fundamentally 
wrong with neurotic and psychotic patients is that they have 
become fixated sexually in one or more of the above-mentioned 
stages, that they have not grown up sexually, or that they have 
regressed from what was a perfectly normal sexual development 
to one of the infantile periods. In the neuroses the amount of 
regression is almost negligible, in the psychoneuroses it dates 
back to the latent period and in the psychoses the regression is 
right back into the earliest years of infancy. 

Of course the patient does not know that this is what is the 
matter with him; even the manifestations of this undeveloped 
stage are unacknowledged and repressed into his unconscious. 
They appear in symbolic form only; and this fact, when con- 
sidered in combination with the “ polymorph-perverse ’’ nature 
of the normal child, affords the real explanation why a funda- 
mental understanding (I almost wrote “ diagnosis ’’) of neurotic 
and psychotic conditions is so extraordinarily difficult. Indeed 
we have considered only symbolization; but all the mechanisms 


186 MIND AND ITS DISORDERS 


of dream distortion are at work in the creation of neurotic 
and psychotic symptoms, including condensation, displacement, 
representation of the opposite and dramatization. 

As we have already remarked, a neurosis or psychosis is really 
nothing more or less than living a dream. When, then, we 
consider the difficulty of interpreting a dream with the aid of 
the conscious mind of the dreamer, we can readily understand 
the extraordinary difficulty in the interpretation of neurotic 
and psychotic symptoms in those cases in which the patient is 
incapable of rendering similar assistance. 


TECHNIQUE. 


It will already have been gathered that psycho-analysis is a 
method of investigating the unconscious of a patient, or anyone 
else for that matter. How can this be done ? 

In the first instance, a person’s unconscious is inaccessible to 
himself and it must necessarily be still more inaccessible to any 
other person. It is obvious that the only one who has sufficient 
knowledge of the patient’s individual experience and modes of 
thought to throw a light on the matter is the patient himself. 
This leads us to the first principle of psycho-analytical technique, 
viz., that the patient must tell everything that occurs to his 
mind to the analyst and keep nothing back. 

As with all patients, whatever their ailment may be, the first 
task of the physician is to take a detailed history of the case, 
symptom by symptom, tracing it back, as far as may be possible, 
to its origin. He obtains details of previous illnesses of every 
kind, and endeavours to ascertain whether they have any rela- 
tionship with the existing malady. Then follows an enquiry into 
the family history, a little more detailed than is usual in general 
practice, with a view to ascertaining the patient’s conscious 
opinions respecting various members of his family. 

Should any organic disease be discovered, this should be 
treated by the patient’s usual medical attendant or by some 
specialist in the particular malady, even though the patient be 
suffering from an obvious neurosis; for it must never be forgotten 
that ill-health of any kind is liable to weaken psychical re- 
pression and thus to allow the unconscious to be more assertive 
than usual, so as to produce intrapsychic conflict. The correc- 
tion of an error of refraction, an abdominal support or the open- 
ing of an abscess may suffice to restore the equilibrium between 
the conscious and unconscious. 


PSYCHO-ANALYTICAL TECHNIQUE 187 


Having once established the fact that the case ought to be 
treated by psycho-analysis, all other attempts at treatment 
should cease. Even the analyst should refrain as much as 
possible from prescribing drugs; but the patient should be left 
entirely in his hands. It will be explained in the third part of 
this manual which disorders are suitable for analysis. Broadly, 
it may be stated that only the neuroses and psychoneuroses are 
really suitable. Moreover, the patient must be fully capable 
of apprehending that his malady is purely psychical in origin, 
and he must be seriously willing to co-operate with the analyst 
in attempting to get to the bottom of it. There are many who 
present themselves for psycho-analysis ina light-hearted fashion 
and make some sort of a beginning, but soon find all sorts of 
reasons for interrupting the treatment. The experienced psycho- 
analyst can usually recognize this type of patient and will devise 
some excuse why the treatment should not be initiated. Other- 
wise the patient will become one of the increasing number of 
persons who go about the world proclaiming that they have 
been psycho-analyzed (obviously without success) and_ bring 
disrepute to the method. 

When, on the other hand, a medical psychologist has decided 
that his patient should be treated by psycho-analysis, it is a 
necessary preliminary to explain that he will require the patient 
to attend at his consulting-room for one hour a day six times a 
week for probably a year, but that the treatment might be 
completed in four months or require a longer period than one 
year, possibly even two years. Arrangements having been 
concluded as to times of attendance, fees and so forth, it is 
permissible to tell the patient that his dreams can be of the 
greatest assistance during the treatment. Dreams are so easily 
forgotten (repressed) that some patients like to write them out 
as soon as they occur. Personally I have no objection to this, 
but some psycho-analysts think it bad technique. 

It is also desirable to advise the patient that the first two or 
three weeks must be regarded as tentative, for it is sometimes 
discovered within this time that he is not really a suitable 
case for analysis and that some other treatment should be 
adopted. 

The emotional reactions which occur during psycho-analysis 
are often very severe and, during those stages when a complex is 
revealing itself but not yet consciously recognized and admitted, 
prolonged for days or even weeks. It is as well therefore to 
forewarn the patient that there may be times when he feels 


188 MIND AND ITS DISORDERS 


worse for the treatment, but he is not then to suppose that psycho- 
analysis is doing him:-harm. On the contrary, these are the 
occasions when he is making real headway. | 

All preliminaries having been settled, the patient begins his 
daily visits. At these he should lie on a couch at the head of 
which the doctor sits, the object of this arrangement being to 
avoid every possibility of suggestion by the analyst, any move- 
ment or change of expression on his part being thus concealed 
from the patient while, on the other hand, the analyst can 
~ scrutinize every movement of the patient. The latter is essential 
because unpremeditated movements of the hands, fingers and 
feet frequently give more reliable information than the organs 
of speech. This is the orthodox posture of the patient, but it 
is quite a common practice to place the patient in a comfortable 
armchair with its back to the analyst, more or less. 

After a brief reference to some unexplained item at the end 
of the previous visit, the patient is told to allow his thoughts to 
wander and without self-criticism to speak everything which 
comes to his mind, even though it appear to be quite foreign 
‘to preceding thoughts or betray a secret belonging to some other 
person. No matter how painful or even disgusting any revived 
memories may be, he must speak them out and tell everything, 
the real object being, not so much that his psychologist should 
know, as that the patient should recognize and acknowledge to 
himself the various items of experience which thus occur to his 
mind. Incidentally they may cause much emotional reaction 
which the doctor should not attempt to allay, but rather en- 
courage.* The doctor says as little as possible, but merely keeps 
the patient to any line of association initiated by him (the 
patient), enquires for more particulars or asks for explanations. 
He tells the patient absolutely nothing and scrupulously avoids 
suggestion of any kind. This method, which has been called 
by Freud “ free association ’’, is the central principle of psycho- 
analysis. It is, of course, permissible to repeat to the patient 
precisely what he has said when he appears to have missed some 
point or to comply with his request to give an explanation of 
a psychical mechanism which has become obvious to him but 
incomprehensible. 


* It has been demonstrated that these emotional reactions are accom- 
panied by changes in the pulse and respiration and by electrical phenomena 
of various kinds. Academically these facts are of very great interest, but 
the practising medical psychologist seldom, if ever, finds it expedient to 
investigate such physical reactions in his patients. 


“"“THE TRANSFERENCE © 189 


The interpretation of dreams also plays an important part; in 
fact, free association is the essential mode of discovering the 
symbolic meaning of the various items occurring in a dream. 
It is permissible to explain to the patient that his dreams, being 
creations of his own phantasy, must of necessity represent situa- 
tions for which he craves, lest he may be inclined to ascribe to 
them a prophetic or otherwise mystical significance. 

Freud has shown that a dream is invariably the fulfilment of 
a wish, usually unconscious; but, owing to the preconscious 
mechanism of the censure or “‘ censor’”’ above described, this 
wish-fullilment is greatly distorted. It is this distortion which 
necessitates an interpretation of the dream. The chief mechan- 
isms of distortion have already been described on p. 100. We 
must here, however, refer to a few more details. 

The affect in a dream is never distorted; it is either the correct 
one for the interpreted situation or its exact opposite. If, for 
example, a normal girl dreams that her lover is unlocking her 
hand-bag with a key, she is usually terrified (conscious reaction 
to the situation after interpretation); but she may be pleased 
and gratified (unconscious reaction); she is not angry, amused, 
disappointed or disgusted. 

The terror in such a dream would exemplify representation of 
the opposite emotion, but this sometimes occurs in other dream 
activities. It may be taken as a rule that when one dream fact 
is inverted in this way, there is always another inversion some- 
where in the dream: 

The analyst is usually portrayed somewhere, usually in dis- 
torted guise, as some other doctor, a clergyman, a pugilist, a 
policeman, a fisherman or sometimes as an inanimate object— 
a breeze blowing through the window, a shed or an instrument 
of torture. These are a few personal examples, whose symbolism 
I leave the reader to discern. The analyst “‘fishes’’ in the 
mind of the patient, and I have appeared in the dreams of some 
patients, not only as a fisherman, but also as Lord Fisher and 
Dr. Fisher (the ophthalmologist). Perhaps the most amusing 
dream-symbolism of myself as an analyst was “‘ a box of Keating’s 
powder ’’ (something which kills the “ little worries ’’ of life); 
the patient was a private soldier during the earlier days of 
the War. 

Transference.—From such dreams it may be gathered that 
the physician is a person of great importance to the patient’s 
unconscious. Indeed, it becomes evident in the course of an 
analysis that the analyst becomes a substitute for various 


Igo MIND AND ITS DISORDERS 


persons who have in the past played the most important parts 
in the patient’s life, especially the father and mother or their 
surrogates. The patient’s unconscious mental activities towards 
such persons become transferred to the analyst, the affect being 
one of anger, fear, hatred, affection or even love. The patient 
is encouraged to admit such feelings to himself, so that there 
is abreaction of the affect with consequent dissipation of the 
transference. In this manner he gradually becomes free from 
all infantile fixations, grows up emotionally and is set upon his 
own feet. Should this transference interfere with the progress 
of the analysis it (the transference) should itself be analyzed and 
thereby dissolved. 

During the course of a psycho-analysis all sorts of difficult 
situations may arise which demand great shrewdness from the 
physician who has to deal with them. For example, certain 
home relationships appear to be antagonistic to the treatment. 
The difficulty can frequently be solved by analyzing the point 
at issue through free associations. If the analysis temporarily 
fails in this particular instance I am not usually in favour of the 
patient seeking a solution in flight—e.g., living away from home; 
for it is necessary that his neurosis should cease to exist, even 
in the most unfavourable environment. When the physician 
is confronted with such difficult problems as these, he will 
act wisely if he consults some other medical psychologist of 
experience. | 

Other methods of exploring the unconscious are by hypnotism, 
crystal-gazing and automatic writing. In most cases, however, 
they fail to elucidate sufficient information to enable the physician 
to cure his patient permanently. Only in recent cases, in which 
the basal complex of the neurosis is not very deep, can much 
assistance be obtained from these methods. 

In a few instances I have succeeded in curing the patient by 
using hypnosis as a mode of treatment after gaining sufficient 
insight into the patient’s unconscious by a short analysis of two 
or three hours; but cases suitable for this method are very 
uncommon. 


CHAPTER VIII. 
ANOMALIES OF THE SEXUAL INSTINCT. 


THE researches of Freud, considered in the last chapter, render 
a knowledge of the various sexual anomalies an essential part of 
the mental equipment of every medical man, quite apart from the 
fact that he may occasionally be consulted about such matters 
directly. For, on the one hand, he will be unable without such 
knowledge to discern the symbolic meaning of the behaviour of 
his patients and, on the other, the time has come when these 
perversions must be faced as psychological, psychiatrical, or even 
everyday practical problems rather than shunned as loathsome 
vices outside the realm of legitimate medicine. 

The whole purport of evolution is perfection of the organism 
for these two functions:—preservation of the individual and 
reproduction of the species. All else is subsidiary to these. 
The pristine significance of the sexual act, by which reproduc- 
tion is effected, renders the study of its anomalies indispensable 
and their unesthetic, revolting, disgusting and criminal character 
does not justify their neglect any more than the loathsomeness 
of a physical disease would exonerate a medical man from dealing 
with it. 

In such a manual as the present, however, it is only possible 
to mention briefly the various anomalies of the sexual instinct. 
Readers desirous of making a more complete study of the subject 
should consult one of the numerous monographs, of which “ The 
Psychology of Sex ’’, by Havelock Ellis, is the most masterly. 

Many of these perversions are extremely common. Some 
authorities, for example, go so far as to suspect over go per cent. 
of the adult population of having been addicted to masturbation 
at some time in their lives. This habit may arise either from 
circumstances being adverse to normal gratification of the sexual 
instinct or from repugnance against the normal sexual act 
(frigidity). In the latter case the victim (taking the male as a 
paradigm) has never escaped from his infantile identification 
with his mother and, in his revolt against the idea of regarding 
himself as a female and seeking conjugal relations with members 

Ig! 


192 MIND AND ITS DISORDERS 


of his own sex, his affection is turned towards himself (narcissism) 
and he commits what is really a homosexual act (loving a person 
of the same sex), which in such guise is unconsciously regarded 
as permissible. 

Masturbation is popularly supposed to be a vice more destruc- 
tive to health than any other and a certain cause of insanity; 
but this notion is erroneous. Masturbation fer se is harmless. 
Psychical auto-erotism or narcissism plays an undoubted réle 
in the genesis of some neuroses (especially neurasthenia) and 
psychoses, as also does the worry the victim suffers from his 
inability to renounce a practice which he supposes to be harm- 
ful, a worry consisting of a conflict between the impulse of the 
unconscious to masturbate and the conscious desire not to do so; 
but the physical act itself does no harm whatever, and victims 
are more readily cured by telling them this than by holding up 
to them the bogey of insanity, as many physicians do. 

Sexual Inversion or Homosexuality is that condition in which 
a person is attracted towards members of his own sex and has no 
desire towards the opposite sex. It is extraordinarily common, 
being admitted by about 5 per cent. of males and ro per cent. of 
females. Some of these indulge in coarse homosexual practices 
known as “ sodomy ”’ or “‘ pederasty ’’ in males and as “ Lesbian 
love ’’, “‘sapphism”’ or “ tribadism ”’ in females. Such practices 
are varieties of mutual sexual gratification. 

To most people homosexual thoughts are naturally repugnant, 
and so it happens that there are many homosexuals, not included 
in the above 5 and Io per cent., who are unwilling to admit this 
peculiarity to themselves. The desire is repressed and they do 
not know—consciously—that they are inverts; so much so that 
they may even marry and beget children. Such unconscious 
inversion is liable to express itself in symptomatic form, and 
thus give rise to psychosis. At least one author goes so far as to 
state that all psychotics are repressed homosexuals. This is not 
true, but it is not far from being true. Intrapsychic conflict arises 
primarily from a reaction against the unconscious homosexual 
tendency, which reaction causes the patient consciously to dislike 
members of his or her own sex to an unusual degree, although the 
unconscious is particularly interested in them. 

A normal person is heterosexual, but not entirely so. Hetero- 
sexuality is not as a rule so strong that he or she is devoid of 
friendly feelings toward members of his or her own sex, but this 
sometimes occurs. 

Just as some people are so right-handed that their left hand is 


HOMOSEXUALITY 193 


practically useless to them and some so left-handed that their 
right hand is practically useless, while most are rather more 
right-handed than left-handed, some slightly more left-handed 
than right-handed, and others again (a very small group) strictly 
ambidextrous; so some people are so heterosexual that any 
member of the same sex is obnoxious to them and some so homo- 
sexual that any member of the opposite sex is obnoxious, while 
most are rather more heterosexual than homosexual, some 
slightly more homosexual than heterosexual, and others again 
(a very small group) strictly ambivalent. I am referring to un- 
conscious tendencies; the conscious mind would, of course, deviate 
an ambivalent person towards heterosexuality. 

Psycho-analysis has revealed that the heterosexual or homo- 
sexual tendency is directly traceable to the way in which the 
subject regards his own father and mother (or their surrogates). 
If the home conditions are such as to cause a child to feel ab- 
normally and persistently dependent upon and thus, or in some 
other manner, to identify himself or herself with the parent of the 
opposite sex, he or she becomes a homosexual; and since the home 
conditions are usually similar for all the members of a family, it 
is not uncommon to find that homosexuality is hable to run in 
families, all or most of the sons or daughters being affected, very 
seldom both. For example, the sons of an eccentric father and 
the daughters of an eccentric mother are liable to become homo- 
sexuals, or neuropaths owing to repressed homosexuality. This 
fact explains the exaggerated importance which has hitherto been 
attributed to heredity as an etiological factor of insanity; there 
are other ways than heredity in which the father and mother can 
influence the life of their children. The importance of this sub- 
ject can scarcely be overestimated, for it has a bearing on many 
problems of the day—education, for example. 

In the above remarks, homosexuality has been utilized as a 
paradigm on account of its frequency; but there are many other 
sexual abnormalities whose repression may result in symptom 
formation. 

In the cases above mentioned, the patient possesses psychical, 
and often physical, characteristics of the opposite sex and their 
desire is usually towards members of their own sex. Sometimes, 
however, we find on psycho-analysis that such persons have 
desire towards members of the opposite sex, so that they are, 
in a way, doubly homosexual; for mentally they are of the 
opposite sex and also have desire towards the opposite sex— 
mentally the same sex as themselves, Such individuals often 

13 


I94 MIND AND ITS DISORDERS 


make a happy marriage, although homosexuality usually leads 
to unhappiness in married life. 

There is yet another class:—people whose mentality and 
physique are strongly characteristic of their own sex, yet whose 
desire is towards members of their own sex—preferably those 
who resemble in some way members of the opposite sex, for 
example—very masculine men who seek sexual gratification with 
boys (the Oscar Wilde type). This is really a variety of the 
obsessional neurosis and can sometimes be cured by psycho- 
analysis. 

The first variety is incurable; psycho-analysis can no more 
render such people heterosexual than it could hope to make 
heterosexual people homosexual. 

Sadism and Masochism (active and passive algolagnia), which 
appear to be extraordinarily widespread, belong to an entirely 
different category. 

A sadist is a person whose sexual instinct is stimulated and 
gratified by inflicting pain, cruelty or degradation on others. 
Whipping is the prototype of such humiliations and it may 
suffice to see the pain inflicted by another person, to hear the 
cries of the victim, or even to hear or read some story of torture. 

There is an infinite variety of methods of inflicting pain which 
appeal to sadists, not excluding murder. The Whitechapel 
murders by “ Jack the Ripper’ in the last century were a 
typical example of sadism. It is not necessary that the victim 
should be a woman or even a human being. Bloch relates the 
case of a man who used to kill a hen at every sexual debauch. 
Some instances of the violation of female children should probably 
be classified in this category. Theft sometimes occurs as a 
sadistic act. The infliction of pain is the chief pleasure to some 
sadists, while others are more gratified by the helplessness of the 
victim or by his degradation. 

A masochist is a person who seeks and submits to pain, torture 
or degradation, sometimes of the most disgusting character, in 
order to stimulate and gratify his sexual instinct. He loves to 
be bound and scourged with rods and whips, perhaps till blood 
flows, or to be treated as a slave or a dog—e.g., to lie at his 
mistress’s feet and have bones thrown to him, or, at least, to 
imagine himself in such situations. Many women wear painfully 
tight shoes, corsets or gloves for the sake of the sensual effect 
produced by such articles of clothing. 

Masochism and sadism are vindicated on the ground that their 
occurrence in one form or another is quite common throughout 


SADISM AND MASOCHISM I9Q5 


the Animal Kingdom. The cock uses his spurs on the hen, cats 
bite and scratch their females during coitus and stags beat their 
does with their horns in courtship. . 

In man the sadistic tendency is born of a special aggressiveness 
in childhood, which takes the form of an intensive desire to learn 
about sexual matters and the mystery of birth by gazing and 
peeping on the one hand and by aggressive questioning on the 
other. This interest is usually aroused by parental indiscretions 
in the presence of the child, witnessing coitus between animals 
and such-like. The latter is indeed generally regarded by children 
as a combat. 

Masochism similarly dates from the infantile period when a 
child loves to expose its own body. In adult life such an action 
would assuredly symbolize submission. Indeed it is something 
more than symbolism when in tender years an intimate part of the 
body is exposed in order to receive punishment by the infliction 
of pain. 

Sadism and masochism usually occur together in the same 
individual, one or the other preponderating. Dr. Ernest Jones 
has traced their deeper origin to repressed anal erotism in most 
cases, while in others Abrahams has traced them to repressed 
oral eroetism. They are not due, as is popularly supposed, to 
corporal punishment received in childhood. Sado-masochism is 
a perversion in which the subject obtains sexual gratification by 
inflicting pain of some sort on himself. 

The above-mentioned tendency to gaze and peep at objects of 
sexual interest sometimes persists into adult life, the victims 
being generally known as “‘voyeurs’’ or peepers (scoptophilia). 
The infantile tendency to expose the body to the public gaze 
finds an annual outlet at the seaside; but some, usually males, 
find pleasure in bizarre exposure of the genitalia. Such are 
known as “‘ exhibitionists’”’. This peculiarity possesses a sadistic 
element in the desire to give offence to others and a masochistic 
element in the wish to obtain a bad reputation. Like active 
and passive algolagnia, scoptophilia (pleasure of looking) and 
exhibitionism are usually combined in the same individual, one 
or the other preponderating. 

When algolagnia is repressed it usually finds expression in one 
or more of the various symptoms of the compulsion neurosis 
hereinafter described. Self-punishment is also the root of many 
hysterical symptoms and of melancholia. 

The Role of the Senses.—Normally, attraction to the opposite 
sex is stimulated by an appeal to the senses, The fouch of a 


196 MIND AND ITS DISORDERS 


loved one in any part of the body is a stimulus to the sexual 
instinct. Kissing, apposition of the breasts and congress of the 
external genitalia in the embrace of opposite sexes are to be 
regarded as normal; but perversions occur in the form of fellatio 
(apposition of the male genital organ to the mouth of another 
person) and cunnilingus (apposition between female genitalia 
and the mouth of another person). In some cases the anal canal 
is made to do service for the female genitalia, even between 
husband and wife, the sexual orgasm being thus aroused in both 
parties (sodomy). 

Sexual desire is stimulated in some persons by touching fur, 
velvet or some other material or object used in female attire. 
When this-peculiarity is so magnified as to be effective by itself 
it is known as fetichism. 

Viston normally plays an important rdle. A beautiful face, 
a full bust, a well-developed gluteal region, a delicate hand or 
a pretty foot appeal to men in varying degrees; similarly height, 
muscularity and apparent strength, a hirsute face or a bass voice 
in a man may appeal to a woman; but when female character- 
istics in a man or male characteristics in a woman attract a 
member of the opposite sex, such as a contralto or tenor voice, 
this is strongly suggestive of homosexuality, either latent or 
acknowledged. A curious transfer of the affect takes place in 
certain individuals who attach undue importance to clothing 
so that gloves are more effective than hands, corsets more than 
figures and shoes more than feet. This is another variety of 
fetichism. Underclothing, garters, stockings and handkerchiefs 
also commonly serve as fetiches. Women’s hair, too, is often a 
fetich, to such an extent in some men that they will seek oppor- 
tunity to cut off whole plaits or large-portions of the tresses of 
their victims with scissors. Wig-collectors are less objectionable 
hair fetichists. 

Smell appears to play a large part in the sexual life of some 
persons. There are many distinctive odours about a woman: 
the hair, the sweat, the warm breath extolled by some novelists, 
the axille, the breasts (especially during lactation), the perineum 
(especially during menstruation) and the feet, as well as a 
combined odour of the whole individual. All of these have 
their devotees, whose predilections may induce them to steal 
ladies’ handkerchiefs or, if possible, articles of underclothing. 
In this connection the use of artificial scents for purposes of 
sexual allurement will naturally occur to the reader. 

Taste probably plays no part in sexual life and hearing very 


SEXUAL ABNORMALITIES 197 


little, but the sound of a voice or of the rustling of female clothing 
is sometimes effective as a fetich. 

Bestiality (connection with animals), occurring in both sexes, 
and necrophilia (violation of corpses), a vice limited to males, 
may also arise as a result of circumstances; but there are indi- 
viduals who indulge in such depravities from choice. 

Pygmalionism may here be mentioned, a curious perversion 
whose subjects are liable to fall in love with statues. They 
sometimes masturbate before statues, even of the Virgin Mary. 

The victims of fetichism, bestiality and pygmalionism some- 
times refuse to admit to themselves that such peculiarities form 
any part of their psychology, and they thereby repress them 
into their unconscious. The strife of such tendencies for recog- 
nition under such circumstances may give rise to symptoms, 
usually of a compulsive or obsessive nature; but I have also 
come across them (repressed) in several hysterical patients. 

Sexual perversion in itself, especially sexual inversion, can 
scarcely be regarded as a sign of degeneracy, for it claims among 
its victims men of the highest rank and intelligence. It is re- 
pression of the perversion that is dangerous to mentation. On 
the other hand, there are many cases of insanity in which some 
sexual perversion, such as znucest or clamour for free love, which 
has not hitherto been mentioned, has occurred as a symptom, 
and many more cases in which some perverted sexual incident 
has served as a factor in the patient’s malady. The perversions 
discussed in this chapter are not by any means all that exist, 
and in psycho-analytical investigation we hear of many more 
phantastic repressed sexual perversions, which probably never 
occur in actual life, some being physically impossible of per- 
formance. . 

The treatment of manifest sexual perversion is often very 
difficult. The practitioner must be warned to be very cautious 
in advising marriage to sexual perverts, and it should never 
be advised to sexual inverts in the hope that heterosexuality 
will develop. 


PAIR Site 
MENTAL DISEASES. 


CHABTERSIE 
THE CAUSATION OF MENTAL DISORDER. 


THE specific causes of the various psychical disorders will be 
discussed in the ensuing chapters, separately devoted to indi- 
vidual mental maladies; but it will be helpful to take a broad 
preliminary survey of the etiology of mental disorder in general. 

The first part of this manual comprises an account of physio- 
logical psychology, which derives all psychical processes from 
sensation. The principles there enunciated are scientifically 
accurate and they provide us with a serviceable classification of 
mental mechanisms, upon which we can base our description of 
symptomatic deviations from the normal, but it must be ad- 
mitted that this laboratory psychology has contributed practi- 
cally nothing to our discernment of the fundamental nature of 
diseases of the mind, because laboratory psychology is rather out 
of touch with the psychology of everyday life. 

Modern psycho-analytical psychology, on the other hand, has 
taught us that, for practical purposes, the core of our daily 
mental life is not sensation, but desive. Our mental life consists 
of a constant endeavour to do what we want to do, to gratify 
our desires, to fulfil our wishes. Yet psycho-analysis has 
revealed another important truth, that many of our desires are 
unknown to ourselves, unconscious and even in direct antagonism 
to our conscious wishes. 

This state of affairs naturally gives rise to intrapsychic con- 
flict; but such conflict is usually avoided, as we have seen, by 
sublimation, whereby the gratification of an unconscious wish is 
achieved in a disguise acceptable to conscious thought. When, 
from any cause, sublimation fails and an unconscious wish 
threatens to assert itself in consciousness undisguised, the result 
is intrapsychic conflict, an unbearable situation which is avoided 


by flight into some mental disorder which is more tolerable or, 
198 


HEREDITARY INFLUENCE 199 


at least, the best way out of the difficulty. In this sense mental 
disease is nothing more or less than an adjustment of the per- 
sonality. In some cases the manifestations of the malady may 
be physical (hysterical paralysis and “ functional’’ tachycardia, 
for example), but we must never lose sight of the fact that such 
maladies are of mental origin; in fact, we now know that the 
time-honoured epithet ‘“‘functional’’ means “‘ psychical ’’— 
nothing more or less. 


The neuroses, psychoneuroses and biogenetic psychoses originate 
from this intrapsychic conflict alone; but there are other mental 
diseases whose psychical manifestations bear a remarkable 
resemblance to these, but whose incidence is clearly traceable 
to physical causes—for example, alcoholic intoxication, fever 
delirium and organic brain disease, such as general paralysis. 
In such conditions, however, the mental symptoms are due to 
intrapsychic conflict in exactly the same way; they differ merely 
in the fact that the failure of sublimation or repression is due, 
not to the abnormal strength of the complex which causes it to 
burst its bonds, but to the organic affection of the brain weakening 
the repressing forces. 

In the chapters on the emotions and instincts it was pointed out 
that organic disease affects the more recently evolved volitional 
system more than the pristine instinctive system and tends to 
let loose the activities of the latter, and it is not assuming too 
much to say that the volitional system is the physical basis of 
conscious and preconscious repressing forces. The effect of 
organic affections of the brain is therefore to weaken the repressing 
forces, so that complexes, which would otherwise have remained 
repressed, are allowed to battle on equal terms with the repress- 
ing forces, the result of such conflict being mental disorder 
resembling that of the biogenetic psychoses or neuroses. 

The recognition that intrapsychic conflict is the fundamental 
cause and essence of all mental disorders, whether functional or 
organic in origin, must be taken into account in considering all 
other etiological factors. | 

If, for example, there is anything in the old doctrine that 
heredity is responsible for nearly 50 per cent. of all cases of 
insanity, we would have to suppose that nearly 50 per cent. of 
the insane are born with an inherently defective volitional 
system, implying inherently weak repressing forces, which (in 
the light of our present knowledge) seems rather absurd; but, 
as a matter of fact, we are now realizing more and more that 


200 MIND AND ITS DISORDERS 


there are other ways than heredity by which a person may be 
influenced to his detriment by other members of the family who 
come into frequent contact with him in his earliest years, especi- 
ally the parents. Eccentricity or other mental abnormality of 
the father is especially liable to affect the daughters, while 
peculiarities of the mother are apt to work upon the sons by 
directing the childish libido to the parent of the same sex and 
thus tending to induce a homosexual tendency, which may be 
repressed in later life and then be forced to find expression in 
psychotic symptoms. 

Such considerations have to be taken into account in consider- 
ing all statistics hitherto published, which bear on the subject 
of heredity in mental disease, and perhaps render them valueless; 
but, to be fair, it ought to be mentioned that Rosanoff and Orr, 
from the study of 72 families, representing 206 marriages with 
a total of 1,097 descendants, came to the conclusion that neuro- 
pathic heredity follows the Mendelian law, assuming normality 
to be “dominant ’”’ and “‘ neuropathy’’ to be “ recessive’. I 
have not studied their paper with sufficient care to satisfy myself 
whether I consider their conclusion to be justified or not. 

With a view to determining the importance of heredity as an 
etiological factor of insanity, Otto Diem of Herisau compared 
the parentage of 370 sane and 370 insane people, with the follow- 
ing results: 


Parents of | Parents of 
370 Sane. | 370 Insane. 


Insanity ar on a ae ao 17 68 
Alcoholism ie o — = v7 32 63 
Senile dementia oe = 45 ue I 10 
Eccentricity afi rv ~ ae the 22 67 
Suicide a ay Ms a cis 2 4 
Total abnormal oA ie a ele 74 212 
Total normal me Bd me ah 666 528 
Total of all parents .. he <a s 740 740 


Hereditary influence is said to be direct when the father or 
mother of the patient has suffered from mental disease; but this 
is of no importance, for it is now recognized that the parents 
contribute nothing to their offspring but their ova and sper- 
matozoa, which originate from cells specially set apart for the 


HEREDITARY INFLUENCE 201 


purpose of reproduction during the early stages of their own 
foetal life. This doctrine is known as the “continuity of the 
germ-plasm ’’; but it accepts, of course, the fact that the fertilized 
ovum is nourished by the maternal blood. 

Heredity is said to be collateral when mental disease occurs 
only among the brothers, sisters, uncles, aunts or cousins of 
the patient. 

When any of the grandparents or more remote ancestors, but 
not the parents of the patient, have been mentally afflicted the 
hereditary influence is said to be atavistic. We need not nowa- 
days discuss how many generations are necessary to exhaust the 
influence of atavistic heredity, for Lombroso and Lacassaigne long 
ago suggested that the brutality of certain criminals is atavistic, 
dating from their ancestry in the wilds of the forest, and we now 
know that the basest animal instincts exist in the unconscious 
of every one of us. Fortunately they usually find expression 
through sublimation into useful activities. 

There is an ill-founded popular notion that the children of 
parents related to one another show a special predisposition to 
insanity. If a neuropathic tendency has already shown itself in 
the ancestry of such parents their union in wedlock renders the 
evil hereditary influence cumulative; but if those parents come 
of a healthy stock their offspring will not only be free from any 
tendency to disease, they will have the advantage of cumulative 
tendencies to health. _ 

The various members of some neuropathic families tend to 
develop the same type of nervous disease; in these cases, the 
hereditary influence is said to be s¢milay and the family charac- 
teristic may prove helpful in framing a diagnosis and prognosis. 
In other cases the family shows a general neuropathic tendency 
to develop heterogeneous affections of the nervous system bearing 
little resemblance to the diseases of the ancestors; the hereditary 
influence is then said to be dissimilar. Some patients not only 
develop the family disease, but do so at the same age as other 
affected members of the family. More commonly, however, we 
find that nervous disease tends to appear at an earlier age in 
the children than in the parents. 

From observations on my own patients I am inclined to the 
opinion that the proportion of cases of “‘ similar heredity ”’ is 
much larger than is usually believed and that the distinction 
between similar and dissimilar heredity is therefore justifiable. 
Mott, on the other hand, is of the opinion that the type of mental 
disorder in a family tends to become more and more degenerate, 


202 MIND AND ITS DISORDERS 


maniacal-depressives begetting dementia preecox, and _ this 
begetting idiocy for example, so that the degenerate stock is 
brought to an end. 

Although marriage with a psychotic individual is usually in- 
advisable on personal grounds, the view is generally held that it 
is quite possible to regenerate a degenerate stock by suitable 
matings with healthy individuals, and the latest eugenic idea 
is that the choice of a mate for a psychotic person, or even for a 
healthy person, should be State controlled. This nation has 
recently seen enough of State control to teach it that those who 
contemplate extending this principle do not understand human 
psychology. Similarly, the oft-suggested sterilization of the 
insane is not only antisocial interference, but it is totally un- 
warranted by our knowledge of the causation of mental disease. 

From the accompanying tables, taken from the Commis- 
sioners’ Report for 1903, and from the chart which I have con- 
structed from Table III., many lessons may be learned with 
regard to the relationship of age, sex and civil state to the 
incidence of insanity. 

It will be seen that insanity is at least twice as common in 
the single as in the married. That this fact is not due to any 
avoidance of marriage on the part of the neuropaths is shown 
by the frequency of mental disease among the widowed; insanity 
appears to be directly caused by the evil influence of a single life 
and by enforced repression of the sexual instincts and complexes. 
It is, in fact, now definitely established that the anxiety neurosis 
and some cases of anxiety hysteria are induced by sexual excita- 
tion without gratification. A further explanation of the high 
incidence of mental disease in the unmarried is that married 
life does not appeal to those who are sexually perverted and 
therefore remain single. If the sexual perversion is repressed — 
they are unconscious of the real reason why they remain single 
and, on the other hand, their perversion is liable to find expression 
in psychotic symptoms. 

The curve for the married men shows little more than an 
increasing tendency to insanity as age advances; there is a slight 
rise in the curve at middle life, probably due to the incidence 
of general paralysis during that period. During the child- 
bearing period insanity is more common in married women than 
in married men. . In all other instances, insanity is proportion- 
ately more frequent in men than in women. This appears at 
first sight to be rather surprising in view of the fact that homo- 
sexuality is much more frequent in women than in men; but the 


tE CENSUS OQ 
f the Census 


| 


Total. 


3 688,469 
3 3,117,2591,1 
[| 190,277 


1 ‘‘ widowed,”’ 
age; and that 
sons were adn 


TABLE I. 
SHOWING THE AGES or ALL PERsons IN ENGLAND AND WALES AT THE TIME OF THE CENSUS OF I901, WITH THEIR CONDITION AS TO MARRIAGE. 
(Taken from Table XXIX. of the Summary Tables of the Census of April 1st, 1901.) 


| Total. 
Under 15. I5—1I09. 20—2 aa" a se BGS 64, 65 and upwards. 
Condition 2 Se | at 22 d 25—34 5 =D 44 45—54 : 
= | | | | | | | Total Mal Females Total. 
Marriage. Males. | Females.| Total. | Males. | Females. | Total. Males. | Females.| Total. | Males. | Females.| Total. | Males. Females. Total. | Males. | Females.| Total. | Males. | Females., Total. | Males. | Females. otal. ales. : 
—— | | | | | | | | | ee a ees 
: l | ee ae eee ee eee ee ee ty [poe ae me | 88 
— 5,265,324 5,280,415 10,545, 739|1,603,066|1,613,138 3,216,204 1,216 628 1,196,555 2,413,183 892,226 941,161/1,833,387| 306,001] 382,468 688,469] 154,118 205,176 359,294; 80,494 | 121,038) 201,532| 49,045| 95,335| 144,380 See ea oer 
eo Sf wa 4423) 25,392) 29815) 254,169 447,885 702,054 T, 569,094 1,781,022) 3,350,116|1,567,616|1, 549,643 3,117,259/1,143,059 1,061,938, 2,204,997] 693,550 | 589,380/1,282,930/379,470 | 262,277 | ceig! 5, ae z med coe coe Poe 
idowed SS == — aS “QI| 124| 1,847 3,838, 5,085 24,024| a7, 703 | — 72,437) — 58,320 131,95%, 190,277] 99,032) 238,868 337,900] 133,901 | 324,887, 458,788/323,557| 499,069 | 731,62 55 iso 2 Seas 
———S —— : | i ) | es Se 
Total 5,205,324 5,280,415 10,545,739|1,607,522|1,638,621 3,246,143 1,472,044 TOsS e981 sac92 2,485,954 2,709,886) 5,255,840 1,931,943 2,064,062 3,996,005 T; 39,209) 1,505,982)2,902;191 907,945 1,035,305,1,943,250/661,072 | 856,681 I,517,753\||15,729,6013 | 16,799,230 32,527,843 
| | | | | 
TABLESIL: 
SHOWING THE YEARLY AVERAGE OF THE NUMBER OF PATIENTS ADMITTED INTO COUNTY AND Boroucu AsyLums, RecIsTERED Hospirars, NAVAL AND Mititary Hospirars, State ASYLUMS AND LicENSED Houses IN ENGLAND AND WALES 
DURING THE FIVE YEARS 1898 To 1902 INCLUSIVE, WITH THEIR AGES AND CONDITION AS TO MARRIAGE. 
| 
Under 15. [5—10. 20—24. 25a et sae Aaa4s 65 and upwards. | Total. = 
Condition ———____— = ee a Se ee ee = =. AS i i — 
as to | | | | | l Total 
Marriage. Males. Females. Total. | Males. | Females.| Total. | Males. | Females.| Total. | Males | Females.| Total. | Males. | Females.| Total. | Males. Females., Total. | Males. | Females. Total. | Males. | Females.| Total. Males. | Females. otal. 
Single 151 103 254 | 466 432 808 866 | 752 1,618 1.495 1,202 2,697 | 802 812 1,615 306 502 898 = 196 246 442 | 109 185 | 2904 || 4,482 | 4,234 8,715 
Married = = a — I Io II 41 LO3— 4} - 234 659 1,077 1,736 1,34 9=+|\--1. 206 2,632 1,105 1092 ei oe. 726 544 1270 472 263 TaD 4,345 | 4,409 | 8,754 
Widowed —= i ae — — -- I al 4 2 46 71 104 192 206 179 344 | 523 225 407 ee | Santer | 660 1,052 926 | 1,651 Petre 0 
Unknown = — | — 2 == = 2 2 4 16 5 2Y 29 8 37 20 9 | 29 12 3 15 | 10 3 13 go 30° | 120 
\ | | | 
Bias ees ee Cl oe ey 467 442 go09 O10 meOe0 1,859 | 2,195 25330 |. 4,525.1 2.278) 2 401 4.570. 1,700 1,887 | 37587 1,159 I,200 2,359 | 984 Tamar 2,095 | 9,843 10,324 20,167 
TABLE-1Uie 


SHOWING THE RATIO (PER 10,000) OF THE YEARLY AVERAGE NUMBER OF PATIENTS ADMITTED INTO CoUNTY AND BoroucH AsyLuMs, REGISTERED Hospitats, NavaL AND Mititary Hospirats, STATE ASYLUMS AND LICENSED HousEs IN ENGLAND AND WALES 


DURING THE FIVE YEARS 1898 TO 1902 INCLUSIVE, TO THE GENERAL POPULATION (AT THE TIME OF THE CENSUS OF I901), ARRANGED ACCORDING TO THEIR AGES AND CONDITION AS TO*MARRIAGE. 


Under 15. I5—I9Q. 20—24. 25—34. 35—44. | 45—54. 55—64. 65 and upwards. Total. 
Condition = = ee el a ————SS - —— - ——— eee ~ = - —ar er == = 
as to | | | | | | | | | | | 
Marriage. Males. | Females. Total. Males... Females. Total. | Males. | Females.; Total. | Males. Females. Total. | Males. | Females. Total. | Males. | Females.| Total. | Males. | Females. Total. | Males.| Females. Total. | Males. Females. Total. 
| | | | | = | He Bs 
| 
Single 0°3 O°2 0-2 20a ge 225 Vik toe im Se 6°7 16°8 12°) 14°7 26°2 22 23°51 2520 24°5 25°O 24°3 20° 21°9 Pe Mages = Seo | 20°4 || 4°7 4°3 4°5 
Married — == -— PIE as ean 6 51 Eo Rome 6, 4°3 303 4°2 6:0 5°2 8-6 8-3 8°4 9°7 0°7 0°7 10'5 g°2 9°9 T2°4 |b Toso II*5 77 7°7 ae 
Widowed —- — = — = — 5°4 7°8 7:0 IOrL 9°6 9°8 17°8 14°6 15°60 IS‘ TA ee eine 16:8 1225 salam Tes 169 eee 144 | 16°8 Ess2 14°3 
| 
| | 
Total 0°3 Or2 0-2 2°9 207 2° Sete 6°2 | 5°8 6:0 Sl ees a) ie carcass CT 11°8 nie ig 12°20) 125 | 124 12°8 Tr6 P207 14°9 I3°0 1 ee. 6°3 | 6°1 Gaz 
| | | | 


Note.—It will be observed that in nearly all the above periods the proportions of the “ single ”’ considerably exceed those of the ‘“‘married’”’ and “widowed,’’ while in the total of all ages these ratios are reversed. This is due to the facts 
population under twenty years of age were “‘ single’; that three-quarters of the “ single’’ population were composed of persons under twenty years ofage; and that the numbers of patients 
The above table shows that, at the marriageable ages, and in proportion to the general population, considerably more single than married or widowed persons were admitted. 


that nearly all the persons in the 
under that age who were admitted into asylums, etc., during the five years were relatively few. 


(To face p. 202. 


THE LIPRARY 
OF THE 
UNIVERSITY OF ILLINOIS 


Ratto Age 


Per 10,000 


35-44 
45-54 
55- 64 

65 glipwoa rds 


g a + + 
of Sane Bm ah 
Population | " 6 4 
atsameage)} 3S ~ NS 


es |e a i 
tt 
aia 
Ras 
BRAS 


Sa 
me 
| 


SPITS 
Saas 


ee 
Seat /2sam 
ERR VME 


| et a ae 
2a ees saa 
| ae FL a 
Ue] pees] Sea a a 
ARSE LMSC 
Ff 
aff 


4 
3 
2 
7 
0 


Insane Bachelors 
" Spinsters 
sda ane a pe Widowers 
»  +Widours 
oy eer : Married Men 
. Women 


Fic. 25.—INCIDENCE OF INSANITY IN RELATION TO MARRIAGE. 


To face p. 203 


ETIOLOGY OF INSANITY 203 


incongruity is easily explained by the fact that homosexuality 
can be more easily sublimated in women, into intimate friend- 
ships, for example, which are more tolerated between women than 
between men. The legitimate spheres of activity for women 
also afford more suitable outlets for the complex. 

On the other hand, the female insane population exceeds the 
male insane population, both absolutely and relatively, 35:77 per 
10,000 of the male population being certified as insane, as against 
39°12 of the female.* This discrepancy may almost entirely 
be accounted for by deaths from general paralysis, since (when 
these statistics were compiled) 1,100 men died annually in 
England and Wales of that disease, but only 300 women. 

Before or during menstruation women are liable to exacer- 
bation of their mental symptoms because sexual desire is strongest 
at these times and therefore tends to escape repression and, 
during the menopause when there is also an augmentation of 
the sexual instinct, there is an increased liability to develop 
mental disorder of some kind. 

The gradually increasing tendency to mental disease as age 
advances is probably to be explained by the fact that the uncon- 
- scious is constantly growing at the expense of the conscious. 
The unconscious of an old man is therefore much more volu- 
minous, so to speak, than it was when he was yet young. More- 
over, the abiotrophic tendencies of senility would make for 
weakening of the repressing forces. 

The exogenous causes of insanity are either mental or physical. 
Worry of various kinds is the most frequently ascribed mental 
cause of an attack; but it is commonly found, on probing the 
matter, that worry, which is nothing more than “ meeting 
troubles half way ’’, was only the first symptom, not the real 
cause. However, there is not the shghtest doubt that the onset 
of many attacks of insanity is determined by the “ loss of rela- 
tives and friends’’, ‘“‘ business anxieties and pecuniary diffi- 
culties’”’. Still, it is doubtful whether such causes are as frequent 
as the statistics of the Board of Control represent them to be. 
In cases which have been ascribed to business worries or pecuniary 
difficulties we often find on inquiry that the patient’s affairs are 
fairly satisfactory and that the sole cause of the worry is his 
inability to appreciate his true financial position. When a 
person becomes depressed he worries over trifles, even imaginary 
ones. 

“Fright and other forms of nervous shock”’ are said to be 


* Figures based on the insane population of 1906 and the census of 1901. 


204 MIND AND ITS DISORDERS 


responsible for more than 1 per cent. (according to the statistics 
of the Board of Control) of the admissions to asylums; but here 
again we must be on our guard and recognize that, of all the 
people exposed to such influences, a certain number are already 
on the verge of a nervous breakdown. Cases undoubtedly occur 
which are directly traceable to such incidents as seeing a friend 
killed or waking to find a bedfellow dead. Acute confusional 
insanity is the usual result. Love-affairs, on the other hand, 
more frequently lead to maniacal excitement; acute delirious 
mania sometimes occurs in such cases, so that the novelist is 
right when he makes his jilted heroine die within a few weeks 
from the excitement of “ brain fever’’. These cases supply a 
severe criticism of the view, which some doctors tend to push 
to its utmost limits, that insanity is always due to a toxin cir- 
culating in the blood.* 

A person with unsublimated complexes is liable to an attack 
of insanity at any time and under any circumstances; hence it 
has happened that almost every circumstance under the sun 
has been labelled the cause of insanity. A man’s religion, 
his education, his profession and nationality have all been 
blamed. 

Religion acts in all sorts of ways. In the first place, it must 
not be forgotten that all religions descend from a primitive 
phallic worship and have many sexual symbolisms in their rites. 
The unconscious knows the meaning of such symbols, but the 
conscious does not, and the rupture of this barrier between the 
two may give rise to mental symptoms. Secondly, the aim of 
most religious teaching is to repress the animal instincts, to 
“subdue the flesh’’, often to a degree which is dangerous to 
mentation. The frequency of psychical maladies among the 
orthodox Jews is dependent upon the very repressing influence 
of their religion and especially the great importance they attach 
to the Fifth Commandment, which fixates the father and mother 
complexes without revealing them to consciousness in their true 
light. A propos the Church of England, Samuel Butler in 
“The Way of All Flesh”’ tritely opines that there could have 
been no child member of the Committee that drew up the 
Catechism. Such religions as theosophy and _ spiritualism 
encourage the formation of hallucinations and contribute a 
relatively large number of obstinately incurable patients to the 
neurotic population; but in fairness to such doctrines it must 


* IT have known many cases, with purely psychotic manifestations, 
unjustifiably treated with vaccines. 


ETIOLOGY OF INSANITY 205 


be acknowledged that their form of mysticism or occultism 
appears to be particularly attractive to neuropaths, and their 
adherence to this variety of religion may well be regarded as 
a symptom rather than a cause. Many who lost their dear 
ones in the War became converted to spiritualism because it 
fulfilled their unconscious wish to be able to communicate with 
the dead. Roman Catholicism is apparently a very satisfying 
religion because this Church plays the role of Mother to its 
adherents, and the impression I have acquired, from rather 
extensive experience, is that Roman Catholics are rather less 
liable to mental disease than members of other religions. Delu- 
sions of wickedness and consequent perdition are rare among 
Roman Catholics. On the other hand, changing from a less 
to a more ritualistic form of religion, e.g., from Nonconformity 
to Church of England and from Church of England to Roman 
Catholicism is frequently, for some obscure reason, a psychotic 
manifestation of evil prognostic significance. 

Of late years an assumed over-education has been advanced 
as a cause of insanity. The notion is obviously erroneous. 
Everybody is more or less educated; but, so far as I am aware, 
there are no statistics to show that insanity is unusually preva- 
lent among the educated classes. The authorities at idiot 
establishments recognize that judicious education has a bene- 
ficial rather than a deleterious influence on their patients. A 
badly-conducted education is of course harmful and children 
that have been “ spoiled’”’ are apt to find themselves unfitted 
for the world they have to live in. ‘“‘Only”’ children and 
“ favourite ’’ children are generally ill-fitted for the world they 
live in and zfso facto specially liable to psychosis or neurosis. 
Moreover, education has hitherto been of too repressing a 
character, especially in relation to sexual matters. The child 
receives no education respecting its own instincts and is even 
forbidden to ask about them, so that its conscious thought is 
early brought into conflict with its inborn trends. 

Mental disease is especially frequent in those professions which 
entail a large amount of worry; but the worry, not the pro- 
fession, should in these cases be held responsible for the disorder. 
It frequently happens that persons of an artistic temperament 
are of an unstable nervous constitution; consequently artists, 
musicians and poets are exceptionally liable to insanity. The 
reason for this lies in the fact that Art serves the purpose of very 
successfully sublimating several sexual perversions, notably 
homosexuality and anal erotism. When Art fails to fulfil this 


206 MIND AND ITS DISORDERS 


function, intrapsychic conflict results which necessitates flight 
into psychosis. 

The incidence of insanity among the several nationalities 
forms an interesting chapter in the etiology of insanity. It is 
difficult to make satisfactory comparisons because provision 
for the insane varies widely in different countries, and the causes 
of insanity in one country may be non-existent in another. 
For example, pellagrous insanity is a common disease in Northern 
Italy, but is almost unknown in this country; and hashish 
insanity, while unknown in the West, is common in the East. 

In comparing the different nationalities of the world we find 
that insanity is essentially a disease of modern civilization and 
that it is most frequent in those countries where civilization 
has made the greatest advances. Mental disorder is not un- 
known among savages, but it is comparatively rare. In almost 
all the textbooks of insanity this effect of civilization is ascribed 
to hurry and bustle and to the struggle for existence among 
civilized people, especially among urban communities, on the 
erroneous supposition that insanity is relatively more common 
in the large cities. Popular lecturers advertise that insanity 
and other diseases are due to defective sanitation, insufficient 
sleep, overwork, poverty, the noise of the streets at night, brain- 
fag, and, as we have just seen, education. 

Now this is manifestly erroneous. Even its premises are false. 
How can anybody bring himself to believe that defective sani- 
tation is a cause of the degeneration of civilized communities, 
when he compares the magnificent systems of sanitation in our 
great cities with their complete absence among savage races, 
among whom degeneration does not occur ? 

Mental disorder can scarcely be said to be common in brain- 
workers and it is certainly very rare in children under educa- 
tion. Overwork, too, is somewhat of a myth. It is true that 
we get through a tremendous amount of work nowadays, but 
this is merely because work is rendered easier by modern scientific 
instruments and labour-saving appliances; and, as regards this 
fierce struggle for existence, we do not know what it is, compared 
with the conditions of existence among primitive peoples. Is 
a savage in debt to his fellows ? His goods are confiscated and 
he is probably killed, perhaps to make a meal for his creditors. 
Is he sick of a disease ? He is carried into the wilds of the forest 
and left there to die. Is he suicidal? The means are placed at 
his disposal that he may kill himself withal. Is he subject to 
attacks of frenzy which render him a source of annoyance to his 


SURVIVAL OF THE UNFITTEST 207 


fellows? They fall upon him and slay him. Thus do primitive 
nations free their country of undesirables. 

Compare this condition of affairs with that of a civilized com- 
munity. The bankrupt is allowed to pay his creditors sixpence 
in the pound; the pauper is luxuriously provided for in hundreds 
of ways lest he should starve, feel the cold of winter or suffer 
any other form of discomfort; he need only do a few days’ work 
to receive a living wage for months (called “ the dole *’); the sick 
and wounded are treated with care and skill never before ex- 
perienced in the history of the world and restored to their families 
to procreate children, perhaps with a predisposition to the disease 
of their father. Melancholiacs are cared for in asylums, restored 
to health and sent forth to the world to beget more melancholiacs, 
instead of being allowed to terminate their disease in Nature’s 
way, Suicide; or, regarding the matter from another point of view, 
they are sent back to their families with the result that the 
unfortunate influence of their psychotic peculiarities upon their 
own children is resumed and maintained so as to make their 
progeny psychotic. 

The pith of the whole matter is this: that among savage 
' peoples the interests of the individual are subordinated to those 
of the race and natural selection is at work; while among civilized 
nations the interests of the race are subordinated to those of the 
individual, natural selection is allowed full play, and the result 
is the survival of the unfitiest. This is the true cause of the 
increase of insanity, if we are to attach importance to the 
doctrine that mental disease, or the psychopathic tendency, is 
inherited. 

But there is an alternative explanation of the fact that insanity 
is essentially a disease of civilization. The most important 
characteristic of civilized communities is repression of all thought 
respecting the animal instincts, which exist in every member of 
the human species, however much he may refuse to admit the 
fact. Now repressed thoughts, aspirations and tendencies are 
liable to escape the repression in disguised, symbolic or symptom- 
atic form under certain conditions, and one of these conditions 
is some abnormal psychical relationship to one or other parent, 
surrogate of the parent, or sometimes grandparent or other 
relative intimately associated with the subject during infantile 
life. Such abnormal psychical relationships are brought about 
by mental peculiarities of the father or mother or the surrogate 
of one of them, at any rate in the child’s mind. In this way 
neurosis or psychosis may be induced, not by hereditary in- 


208 MIND AND ITS DISORDERS 


fluence, but by the child’s personal! experience of its progenitors 
or their representatives in his mind. 

War with its attendant stresses and privations has hitherto 
been regarded as a potent cause of insanity; but our late ex- 
perience of the most terrible war in history is that psychosis 
is not abnormally frequent under war conditions. It is only 
too true that psycho-neurotic, especially hysterical, states such 
as the so-called shell-shock, which is no new disease as some 
would have us believe, were extraordinarily common as a result 
of the War; but they were rarely sufficiently pronounced to 
constitute insanity. Later we will refer to some other neurotic 
conditions apparently induced by the war. 

There is a popular idea that association with the imsane is 
liable to produce mental disorder, and the relatives of an insane 
patient often bring this forward as an argument against asylum 
treatment. This notion is not supported by facts; for about 
40 per cent. of asylum patients are discharged recovered and 
the incidence of insanity among attendants on the insane is 
small. It occasionally happens, however, that two maiden 
ladies, who have lived together and had little communication 
with the outside world for many years, both develop a form of 
paranoia in which they have the same delusions. This condi- 
tion has been called folie a deux, or communicated insanity. 

Superficial considerations would appear to suggest that alcohol 
is a frequent and potent cause of insanity, but it is difficult to 
obtain statistics on the matter because alcoholism is too fre- 
quently regarded as the cause of an attack when in reality it has 
only appeared as the first symptom. Some years ago, alcohol 
was one of the attributed factors of insanity in 4 to 5 per cent. 
of the Bethlem cases, but true alcoholic insanity formed only 
2 per cent. of the cases. It is much less than that now. We 
must, however, recognize that alcoholism is itself a mental dis- 
order, usually traceable to repressed homosexuality, and there 
are further causes behind this. Moreover, the more we investi- 
gate alcoholic psychoses, the more we are led to the conclusion 
that they are ordinary biogenetic psychoses in which alcoholism 
is a Superadded factor. 

The same remarks apply to drug habits and the insanities 
occurring in some cases, apparently as a direct effect of the drug. 

Sexual excess is rarely a cause of insanity, although it is fre- 
quently described as such. A sexual outburst is liable to occur 
in the earlier stages of many insanities in which the patient loses 


PHYSICAL CAUSES 209 


cases sexual excess is a symptom, not a cause. The question 
is often asked: ‘‘ What is sexual excess ?’” No numerical defini- 
tion can be given; sexual excess is indulgence in the sexual act 


- with such frequency as to be deleterious to health. When 


the result is disorder of the nervous system the most common 
form of disease is, in the author’s experience, a mild form of 
chronic nervous exhaustion, somewhat resembling neurasthenia, 
but it is not common. 

Masturbation stands in much the same position. Rarely a 
cause of insanity, it is rather to be regarded as a symptom. 
Neuropathic individuals are frequently addicted to the vice 
because they are often emotionally fixated in the infantile auto- 
erotic phase of development. It is said to be common among 
some geniuses. Voltaire in his later years confessed to having 
masturbated all his life. Masturbation is liable to occur in the 
earlier stages of many forms of insanity for the same reason as 
other sexual outbursts. In some cases of stupor associated with 
peripheral analgesia characteristic of mental disorder, masturba- 
tion arises as the direct result of the anesthesia. Consciousness 
being dependent upon sensation, in states of peripheral anes- 
thesia it is dependent upon sensations arising in the sensitive 
remainder; the patient’s attention is thus directed to the genital 
region and he acquires the habit of masturbation. In some 
persons persistent masturbation induces a state of chronic 
nervous exhaustion closely resembling neurasthenia. True 
neurasthenia, on the other hand, is caused by the conflict between 
the unconscious urge to masturbate and the conscious desire to 
refrain from the act, the result being a more or less successful 
repression of masturbation. 

Functional disturbances of the brain may result from disease 
of other organs. Dr. Head has shown that the pain of visceral 
diseases occasionally gives rise to hallucinations of vision, 
hearing or smell, or to states of depression or exaltation; the 
psychical mechanism of this will be explained later. Pain in 
the epigastrium, often due to indigestion, is especially liable to 
cause depression, quite independently of the possible absorption 
of noxious products of disordered digestion: a blister applied to 
the epigastrium will sometimes cause depression of this nature. 
Possibly the depression associated with constipation can some- 
times be explained in this way. 

Mickle studied the mental symptoms associated with the 
various forms of cardiac and arterial disease. In the earlier 
stages of aortic regurgitation depression is the rule; but in the 

14 


210 MIND AND ITS DISORDERS 


later stages when the heart is failing the patient is usually excit- 
able and exalted. Aortic stenosis is said to be associated with 
impulsiveness, violence and delusions of persecution. It is more 
frequent in general paralysis than in any other forms of insanity, 
syphilis being the most important cause of both general paralysis 
and endarteritis. Mickle stated further that mitral regurgita- 
tion tends to depression, and degeneration of the cardiac muscle 
to motor restlessness. These observations are in accord with 
those of Craig, who found that states of depression are associated 
with high blood-pressure and states of motor restlessness with 
low blood-pressure. Motor restlessness frequently appears in the 
later stages of wasting diseases when the blood-pressure is low. 

Similarly depression is the rule in cases of Bright’s disease, 
the blood-pressure being high; but in the last stages of that 
disease, when the blood-pressure falls, the patient is liable to 
become restless and excited. Uremic states in which the nervous 
system is subjected also to toxic influences are characterized 
by hallucinations, especially of vision, accompanied by agita- 
tion gradually changing to stupor which deepens to coma in the 
terminal stage. 

Diseases of the thyroid may lead to various forms of insanity 
which will subsequently be considered in detail. Pituitary 
defect may also be accompanied by mental symptoms. 

Infectious disease and other exhausting conditions charac- 
teristically give rise to acute confusional insanity. 

Insanity is closely allied to other functional nervous diseases}; 
it is sometimes ushered in by an attack of apparent neurasthenia, 
chorea or hysteria in some form, while one-sixteenth of the 
asylum population of this country suffers from epilepsy. 

Inasmuch as the cerebral cortex is recognized to be the physical 
basis of mind, it might naturally be supposed that mental 
disorder would be a common, if not the usual, result of gross 
organic lesions of the cortex; but, as a matter of fact, organic 
insanity is by no means common. When a person becomes 
hemiplegic as a result of thrombosis of the middle cerebral artery, 
the mental disorder which results is loss of voluntary action and 
perhaps excess of emotional reaction on one side of his body; 
but such mental disorder cannot be characterized as insanity. 
Incidentally a few of these patients become certifiably insane 
and then their insanity is frequently accompanied by symptoms 
which have been regarded as characteristic of organic disease. 
The various types of organic insanity will, however, receive 
consideration in due course, 


CHAPTER IT. 
THE PHYSICAL STIGMATA OF DEGENERATION. 


WE have seen that many cases of mental disease are induced by 
stresses acting upon an unstable nervous system, such stresses 
as have little or no deleterious influence upon the mentation of 
a normal individual; and the question arises whether there is 
any way of recognizing that a given individual runs unusual 
risk of mental disease from exposure to the ordinary stresses 
of life. A medical man may, for instance, be consulted as to 
the possibility of this or that occupation being too strenuous for 
a certain member of a family when another member is afflicted 
with mental disease, the person in question never having shown 
signs of nervous debility. 

Under such circumstances the physician may have to rely 
_ upon the general configuration of the individual and to determine 
whether his limbs and other parts of his body are well shapen 
and proportionate to one another. In other words, he looks 
for the physical stigmata of degeneration. These are of three 
classes: 


1. Anomalies in the shape of the skull, these being dependent 
upon anomalies in the shape of the brain. 

2. Anomalies which show a tendency on the part of the in- 
dividual to revert to an ancestral type (atavism). 

3. Deformities which show evidence of incomplete develop- 
ment. 


Cranial Anomalies.—Marked asymmetry of the skull is to be 
regarded as a stigma of degeneration. Slight asymmetry is 
unimportant, since it frequently occurs in normal individuals, 
especially in the frontal region. 

The normal circumference of the skull is 224 inches for a 
person of average size. A deviation of more than 24 inches from 
this standard in either direction is to be regarded as abnormal, 
although exceptional individuals have been known whose cranial 
circumference measured only 18 inches on the one hand and 
37 inches (hydrocephalus) on the other, whose intellectual 


functions were but slightly, if at all, deficient. 
2I1 


212 MIND AND ITS DISORDERS 


The antero-posterior diameter is normally about 7? inches, 
the greatest transverse diameter being 6¢ inches. 

The binauricular diameter (calliper measurement from one. 
auditory meatus to the other) and the length of the face from 
the root of the nose to the lowest part of the chin should each 
be about 54 inches; and the binauricular arc and naso-occipital 
arc (root of nose to occipital protuberance measured over the 
highest point of the skull) should each be about 14 inches. 

Broadly speaking, an individual is to be regarded as abnormal 
if his measurements differ more than 15 per cent. from the above, 
and as a degenerate if the measurements are more sie. I5 per 
cent. below the normal. 

The cephalic index or index of breadth is found by multiplying 
the breadth by 100 and dividing by the length: 


breadth x 100 
length 


From the hats stocked by hatters we may infer that the usual 
cephalic index in this country is 79. Indices below 77 are said 
to be dolichocephalic; 77 to 81, mesocephalic; and above 81 
brachycephalic. Peterson of New York regards all indices 
between 70 and go as falling within normal limits, but such a 
view is probably too liberal. 

Platycephalus is a condition in which the top of the head is 
abnormally flat. 

Acrocephaly is the dome-shaped skull. It is commonly asso- 
ciated with dolichocephaly and, according to some authorities, 
with genius. 

Atavistic Anomalies.— Man as compared with the lower 
animals is characterized by great development of the cranium 
and small development of the jaws, so that his face is vertical, 
whereas the face of the animal is rather horizontal. Accordingly 
prominence of the jaws with recession of the forehead (prog- 
nathism) is an atavism in man, and therefore a stigma of de- 
generation. The facial angle is the angle, seen in profile, formed 
by a line drawn from the middle of the supra-orbital line to 
the margin of the alveolus between the central incisor teeth of 
the upper jaw, and a line from the latter point to the centre of 
the auditory meatus. This angle is normally about 78 degrees 
in the macerated skull. When the angle is more acute than 
75 degrees, the skull is prognathous. It is not very difficult to 
estimate this angle in the living subject. In any marked case 


h 


OQ 


Fic. 26.—DEFORMITIES OF THE PINNA. 


To face p. 213 


DEFORMITIES OF THE PINNA 215 


the facial aspect is sufficiently striking for prognathism to be 
recognized by the unaided eye. 

Similarly the lower animals, the proboscis monkey excepted, 
have a broad flat nose as compared with man; and a broad flat 
nose in man (except in the black races) is an atavistic stigma of 
degeneration. ; 

Other recognized facial stigmata are great prominence of the 
malar bones and marked asymmetry of the face. 

Deformities of the Pinna.—These are of frequent occurrence 
and, if well marked, of considerable importance. Peterson dis- 
tinguishes twenty-two varieties, as follows: 

1. Abnormal implantation: the ears project too far (Fig. 26, a) 
or are placed too high, too low or too far back on the head. 

2. Excessively large ears. 

3. Excessively small ears. 

4. Too markedly conchoidal shape, the antitragus, antihelix, 
and crura furcata being insufficiently developed; while the helix 
outlines the ear “like the rim of a funnel”. 

5. Excessive or deficient length, excessive breadth of the upper 
part or absence of the lobule. 

6. A long ear with constrictions in its breadth (Fig. 26, 0). 

7. The Blainville ear: asymmetry, usually due to anomaly of 
the left ear. 

8. Absence of the lobule, commonly associated with other 
deformities. } 

g. Adherent lobule inclining downward toward the cheek 
(Fig. 26, c and a). 

10. Stahl ear No. 1. The helix is too broad and coalesces 
anteriorly with the inferior crus. 

11. The Darwin ear, which is characterized by a prominent 
point of cartilage at the upper and posterior part of the rim— 
the point of the ear in lower animals (Fig. 26, /). 

1z. The Wildermuth ear, in which the antihelix is more promi- 
nent than the helix. This is very common (Fig. 26, d). 

13. Absence of the antihelix and crura furcata (Fig. 26, a). 

14. Stahl ear No. 2, in which there are three crura instead 
of two. 

15. Wildermuth’s Aztec ear, in which the crus superius of the 
antihelix is continuous with the helix anteriorly, and there is no 
lobule. 

16. Stahl ear No. 3. The antihelix and antitragus are joined 
together by a ridze and the superior crus is wanting (Fig. 26, 7, 
approaches to this condition). 


214 MIND AND ITS DISORDERS 


17. Reduplication of the helix; overfolding of the helix 
(Fig. 26, g and /; a pin is held in position by the overfolded 
helix in g). 

18. Too large or too small a concha. 

19. The scaphoid fossa is continued into the lobule (Fig. 26, e). 

20. The Morel ear, in which there is defective formation of 
the helix, antihelix, scaphoid fossa and crura furcata. It is 
unfolded, flat and thin at the edges, like a plate, and generally 
larger than normal (Fig. 26, /). 

21. Irregular thickenings of the cartilage. 

22. Various anomalies such as clefts, accessory auricles, and 
abnormal hairiness of different parts of the pinna. 

Of ‘all these anomalies, probably the least important is the 


MonTHS LATER. 


adherent lobule. This occurs in 20 to 30 per cent. of normal 
people, but it is twice as common among degenerates. 

This is a convenient place to mention the so-called “ insane 
ear ’’ which presents a shrivelled appearance as the result of a 
previous “‘ hematoma auris’’, otherwise called “‘ otheematoma ”’. 
Although this occurs among perfectly normal people as the 
result of severe injury to the pinna, especially from blows received 
in the football field, it occurs with abnormal frequency among 
the insane. It is mostly seen in cases of general paralysis, 
epilepsy and katatonia. There is usually, but not always, a 
history of some slight injury to account for the condition, such 
as holding the patient’s head firmly between the hands during 
the process of artificial feeding. 


Siz *f a2v/ OF 


‘YAMO'T AHL NI 
SHAILISOJ ‘MOW UAddQ AHL NISHAILVOAN ‘“SALWIVG GAWNOAAC AO SLSV)— '6z ‘DVT 


‘DEFORMITIES OF THE PALATE 215 


Hematoma auris makes its appearance as a thickening or 
swelling in the neighbourhood of the antihelix. This swelling 
gradually increases in size and may spread over the whole surface 
of the pinna until, after a few days, it looks like a dusky bluish 
egg on the side of the head. In the course of some months the 
swelling subsides, leaving the ear deformed and shrivelled. 

The recognized treatment of the condition is to blister the skin 
over the tumour with liquor epispasticus. 

If the tumour is incised, it is found to contain normal blood, 
separating the perichondrium from the cartilage; but this should 
not be done lest it lead to suppuration. 

Ford Robertson has shown that hematoma auris is the result 
of degeneration of the ear cartilage, affecting at first the cartilage 
cells and then the elastic fibres, which become fluid. In this 
way small cysts are formed near the surface of the ear cartilage; 
the walls of these then become vascularized. The new vessels in 
turn degenerate, rupture and distend the cysts with blood. The 
hemorrhage increasing gradually strips the perichondrium from 
the cartilage and ruptures pre-existing vessels during the process, 
which continues until the pressure becomes sufficient to arrest 
further hemorrhage. The blood then clots and the serum 
expressed from the clot becomes absorbed in the course of a few 
months, during which process the ear shrivels. 

Deformities of the Palate.—In a normal person the arch of the 
hard palate is large and wide with a moderately high vault. 
Generally speaking, the degenerate palate is too high and narrow. 
Peterson classifies degenerate palates as follows: 

I. Palate with Gothic arch. The centre of the cast of the 
palate is somewhat pointed. The arch may have either a high 
or low pitch and it may be short or long. 

2. Palate with horseshoe arch, comparable to the arch of 
Moorish architecture. The alveolus projects into the cavity of 
the mouth, so that a cast is either impossible or has to be taken 
in several sections. 

3. The dome-shaped palate. 

4. The flat-roofed palate. 

5. The hip-roofed palate, in which the antero-posterior arch 
is too pronounced. Artificial feeding may be extremely difficult 
in the case of a resistive patient with this form of palate. 

6. The asymmetrical palate. 

7. The torus palatinus, a bony thickening of variable shape 
in the neighbourhood of the intermaxillary suture. Peterson 
regards this anomaly as the least important of these deformities. 


216 MIND AND ITS DISORDERS 


From a study of the palates of fifty-six patients at Claybury 
Asylum, Dr. E. H. Harrison came to the conclusion that the 
palate indicative of “insane heredity ”’ is a low, broad palate, 
which is shallow or of average depth (114 millimetres) opposite 
the first bicuspids; while the palate indicative of “ general 
degeneracy ’’ (from rickets, congenital syphilis etc.) is charac- 
terized by an increased depth opposite the first bicuspids. 

Other anomalies of the mouth, which are recognized as stig- 
mata of degeneracy, are too much corrugation of the palate 
behind the incisor teeth, malpositions and irregularities of the 
teeth and delayed dentition. An abnormally long tongue is also 
one of the stigmata; the tongue is nearly always too long and too 
wide in cases of Mongolian idiocy. 

The lower jaw may be abnormally developed and in some 
idiots has a bony prominence in the middle of the lower border, 
the “‘lemurian apophysis ’’ of Albrecht. 

The most important congenital anomalies of the eyes in this 
connection are epicanthus (a fold of skin overlapping the internal 
canthus, usually symmetrical), irregular or unequal colouring 
of the irides, coloboma iridis, persistent pupillary membrane, 
retinitis pigmentosa, and high degrees of myopia and hyper- 
metropia sufficient to cause spasmodic strabismus. 

Degenerative Stigmata in the Limbs.—These are asymmetry, 
fusion of fingers or toes, supernumerary fingers and toes, small 


Fic. 30.—SIMIAN THUMB OF A PATIENT SUFFERING FROM 
DEMENTIA PRACOX. 


Diminished internal rotation during flexion of the terminal phalanx. 


thumbs, an unusually large number of fine lines in the palm of the 
hand, and laxity of the ligaments so that the fingers can be 
easily bent back to a right angle; an adult Mongol idiot can 
put his toe into his mouth. I have also observed in cases of 
idiocy and dementia preecox that the thumb tends to face forward 


OTHER DEFORMITIES 217 


Fic. 31.—NoORMAL THUMBS, FLEXED TO SHOW THE INTERNAL 
ROTATION OF THE TERMINAL PHALANGES. 


Fic. 32.—-SIMIAN HAND OF A PATIENT SUFFERING FROM 
DEMENTIA PR2ECOX. 


The thumb faces forward like the fingers. Note also the shortness of 
the little finger and the flatness of the thenar and hypothenar eminences. 


218 MIND AND ITS DISORDERS 


like the fingers, instead of looking across the palm, and that the 
terminal joint of the thumb does not undergo the normal amount 
of internal rotation when it is flexed. These features may also 
be observed in the thumb of the chimpanzee. 

Cutaneous Stigmata.—These are mostly anomalies in the growth 
of hair, such as glabrous chin in men, abnormal growth of hair 
on the face and breasts of women and along the spinal column 
in either sex, and a double or eccentric whorl at the vertex of 
the scalp. Irregular pigmentation of the skin, as in vitiligo, and 
nevi, are also regarded by some as stigmata of degeneracy. 
Adenoma sebaceum is a disease found only in a certain form of 
idiocy. Longitudinal ridging of the nails is said to be indicative 
of a tendency to neuropathy. 

Many regard as stigmata all anomalies showing evidence of 
incomplete development. These include hare-lip and cleft palate, 
meningocele and spina bifida, stunted limbs, congenital disloca- 
tion of the hip, congenital heart disease, hernize, hypospadias, 
epispadias and ectopia vesice, imperforate anus, imperforate 
vagina, uterus bicornis, undescended testicle, and hermaphrodi- 
tism. An unnaturally youthful face surmounting an adult body 
is a Stigma familiar to all. 

General Abnormalities.—Giants, dwarfs and persons in whom 
the relative proportions of the various parts of the body to one 
another are abnormal, are generally to be looked upon as de- 
generates. 

Conclusion.—In view of the existing tendency to ascribe 
mental disease to the circumstances of the patient rather than 
to prenatal influences, the question arising out of this chapter 
is:—‘‘ To what extent are the physical stigmata of degeneration 
due to the environment of the individual and how many of 
them are of congenital origin ?’’ Up to the present time the 
question remains unanswered. 


NEUROSIS. 


THE functional mental disorders are classified as neurosis, psycho- 
neurosis and psychosis according to the age at which the patient’s 
libido has become fixated. In neurosis the etiological factors 
belong to the present or comparatively recent life of the patient 
and not to childhood, as in psychoneurosis, or to babyhood as 
in the psychosis. 

Freud has further pointed out that the fundamental difference 
between a psychoneurosis and a psychosis is that the former is 
the result of a conflict between the ego and its 7d (corresponding 
unconscious) and the latter is the analogous outcome of a similar 
disturbance in the relation between the ego and the outer world 
(reality). There is only one true neurosis, viz., the anxiety 
neurosis. 

Freud classifies neurasthenia as a neurosis, and ascribes it to 
excessive masturbation or pollutions, but he means something 
different from the neurasthenia hereinafter described as a psycho- 
neurosis. Freud’s “‘neurasthenia’’ is more like Kraepelin’s 
“chronic nervous exhaustion ', which resembles true neuras- 
thenia so closely that some writers have called it ‘“‘ acquired 
neurasthenia’’. The causes of this disease are those of acute 
confusional insanity (Chapter XIV.), and masturbation is cer- 
tainly not the only etiological factor. 


CHAPTER TIT: 
THE ANXIETY NEUROSIS. 


ALTHOUGH the causation of this neurosis is of a psychical nature, 
its symptoms are mainly physical, so much so that it is unusual 
for a patient suffering from this disorder to consult a mental 
specialist in the first instance. It receives its name from the fact 
that the symptoms represent the physical accompaniments of 
anxiety or fear. 

Etiology.—It has long been recognized that morbid anxiety is 
a hyper-excitation process, but it remained for Freud to discover 
its source. He made the discovery that the anxiety neurosis is 


begotten of sexual excitations which are unable or not allowed 
219g 


220 MIND AND ITS DISORDERS 


to follow their natural course of leading to either physical grati- 
fication or even conscious desire for this. Now when desire of 
any kind is repressed into the unconscious, it becomes replaced 
in consciousness by its opposite—viz., fear; but not necessarily 
fear of the particular object which is unconsciously desired, but 
an ill-defined apprehension which causes the subject to fix his 
dread upon other objects, especially those which tend to remind 
him of the original object of desire. The reason why the re- 
pression of sexual desire is especially potent is merely that sexual 
desire is infinitely more liable to be repressed than any other. 

The condition which is responsible for the anxiety neurosis 
is, then, sexual stimulation without gratification. This state of 
affairs is most frequently brought about by coitus interruptus 
commonly practised by married couples who do not wish for a 
child; but also by pernicious devices for the prevention of con- 
ception. Intentional abstention, prolonged engagements, early 
widowhood, and enforced separation of husband and wife as, 
for example, during the recent war, are all responsible for a 
number of cases. A disproportion between desire and potency, 
after the age of fifty, for example, is sometimes an etiological 
factor, and a few cases occur as a result of the renunciation of 
masturbation. The above observations are obtained from direct 
clinical investigation, not by psycho-analysis. 

Mental Symptoms.—The patients are usually hypersensitive, 
especially to noise and bright light, sudden accesses of which 
cause them to start. There is little or no disorder of the percep- 
tive faculty, but some authors mention hallucinations as an 
occasional symptom. Volition and attention are only disturbed 
in association with some emotional outburst. 

The chief mental symptom is a general emotional tone of 
anxiety or apprehension. The patients are afraid to open detters 
lest the contents convey bad news; for the same reason, they are 
in terror of telegrams. Any slight passing indisposition, either 
of themselves or of their loved ones, induces alarm that it may 
be symptomatic of some deep-lying fatal disease. All fleeting 
incidents are likewise apt to be misinterpreted. The patients 
exhibit abnormal terror in the presence of any real danger, such 
as an air-raid, which often caused them to fall into a state of 
collapse. The reason for this will be obvious to every psycho- 
logist who has made a study of the unconscious, and the most 
superficial analysis of such patients reveals the phallic signifi- 
cance or symbolism (in their minds) of Zeppelins, aeroplanes 
and bombs. 


ANXIETY NEUROSIS 221 


Apart from this persistent apprehensiveness, the patients are 
subject to attacks of anxiety without any apparent cause. With 
such attacks are frequently associated a sense of impending 
death or any of the circulatory, respiratory, digestive and other 
disturbances below specified. Insomnia is common and is 
sometimes induced by night terrors. Some patients complain 
of vertigo or various pareesthesie. 

Physical Signs.—Although the above-mentioned attacks of 
anxiety are frequently accompanied by the following physical 
signs, they may and usually do occur quite independently of 
conscious anxiety; they must therefore be regarded as rudi- 
mentary symbols or equivalents of anxiety. They are— 

(a) Palpitation, tachycardia, pseudo-angina and cardiac irregu- 
larity. 

(5) Vasomotor constriction, with coldness or blueness of the 
extremities. 

(c) Respiratory oppression, air hunger and attacks of asthma. 

(d@) Dryness of the mouth, nausea and even actual vomiting, 
diarrhoea, bulimia and other digestive disturbances, which in time 
may lead to a certain amount of gastric dilatation, consequent 
' organic dyspepsia and even enteroptosis. 

(e) Perspiration, often nocturnal, and especially of the palms 
of the hands in the daytime. 

(f) Polyuria and frequency of micturition. 

(g) Tremor, fits—apparently of an epileptic nature—and even, 
it is said, loss of consciousness without convulsion. 

Pathology. — The reader will have noticed that all these 
phenomena are the usually recognized physiological accompani- 
ments of anxiety, dread or terror; although fits and loss of con- 
sciousness are extremely rare, as indeed they are in the anxiety 
neurosis. 

The bodily changes above mentioned constitute the whole 
morbid anatomy of the condition, for there is none other. When 
anxiety is repressed from the conscious into the unconscious (as 
well as the desire above mentioned), it tends to find expression 
in symbolic form as one or more of the physical manifestations 
of fear. In accordance with our theory of the emotions, such 
manifestations cannot occur without inducing conscious anxiety. 
This may be repressed in turn and so a vicious circle be set up. 

Now the original view with regard to the pathology of the 
anxiety neurosis was that its foundation is of a physical nature, 
being caused by defect of physical gratification—in other words, 
it is due to a retention of products which should have been 


222 MIND AND ITS DISORDERS 


excreted. Experience teaches us, however, that an adjustment 

of the etiological conditions does not always cure the disease. 

Why ? Because the psychical vicious circle is still active in the 

anxiety neurosis and is obliged to find expression in symptomatic 

guise. It is now, therefore, considered that the foundations of — 
this neurosis are psychical, as well as physical. 

Prognosis.—As long as the two causal factors, sexual stimula- 
tion and lack of sexual gratification, remain operative, the anxiety 
neurosis tends to get worse; but, as a rule, it gradually improves 
and disappears after either of these factors has been removed. 
The anxiety of widowhood, for example, passes away in due 
course. Other cases recover by voluntary compliance with the 
requirements of Nature; but not all, for it is often found that , after 
the specific etiological factors have been adjusted a certain amount 
of anxiety hysteria remains which requires some psycho-analytical 
investigation to complete the cure. For this reason it is not a 
bad diagnostic error to call a case of the anxiety neurosis anxiety 
hysteria; but the converse—so common among neurologists—is 
a bad mistake. For example, these would diagnose anxiety 
neurosis in “shell-shocked ”’ soldiers from the front during the 
War and then utilize their erroneous diagnosis to argue against 
the sexual causation of this disease. But this is a digression. 
So far as I am aware, a fatal issue is unknown; but the possibility 
of suicide should be borne in mind. 

Treatment.—Whenever it is possible for the patient to re- 
adjust his or her abnormal sexual life, this should be done. The 
practice of coitus interruptus must be substituted by a state 
of affairs in which the patient obtains normal gratification, 
and prolonged engagements should be terminated, preferably by 
matriage. 

It occasionally happens, however, that circumstances will not 
allow of this readjustment; for example, the enforced separation 
of young husbands and wives during the War. Under such 
conditions the patients should be treated with anaphrodisiac 
medicines, of which the bromides are the most satisfactory. 
Monobromate of camphor is probably the best, but sodium 
bromide in 10-grain doses three times a day is quite a useful 
drug for such patients. On the other hand, when the patient is 
able and willing to comply with the doctor’s advice, but finds— 
as frequently happens—that the neurosis has rendered him 
sexually anesthetic, tonic aphrodisiacs should be given, of which 
strychnine in some form or other is the best. 

After coitus the blood of the female gives a prostatic Abder- 


ANXIETY NEUROSIS 223 


halden reaction, but only if semen has been in actual contact 
with the mucous membrane of the vagina. I have therefore 
treated a few cases of the anxiety neurosis recently in women 
by the administration of prostatic extract. The results have 
been sufficiently gratifying to induce me to adopt this line of 
treatment in many Cases. 

Lastly, it is sometimes found that the renunciation of an 
abnormal sexual life, even when aided by judicious medicinal 
treatment, is not of itself sufficient to alleviate the disorder. 
It then becomes necessary to resort to psycho-analysis in order 
to reveal those complexes responsible -for the failure, and thus 
to complete the cure. 


THE PSYCHONEUROSES. 


THESE (neurasthenta, hysteria and the compulsion neurosis) differ 
from the neuroses in that they owe their origin, not to existing 
conditions, but to partially or completely forgotten situations, 
incidents or phantasies of childhood, whose persistence in sym- 
bolic form into adult life, or the reactions against them, or 
a compromise between the phantasies and the reactions or 
their symbols, appears in symptomatic form, which may even 
itself be symbolized. 

It need hardly be said that the unravelling of such a com- 
plicated tangle is the most difficult task which can present itself 
to the medical psychologist. There is certainly no such brain- 
wracking work in any other department of medicine or surgery, 
or probably in any other profession. 

At the inception of a psychoneurosis there is frequently some 
exciting determinant which serves as a link with the forgotten 
past and is hence commonly but erroneously regarded as the 
primary cause of the disorder; attention should not be directed 
to this etiological factor so much as to the already existing 
mentation of the individual who has been affected by it. 


CHARTERS Tye 
NEURASTHENIA. 


THIS is a disorder which makes its appearance in early adult life 
and is chiefly characterized by an increased susceptibility to 
fatigue on slight exertion, mental or physical. It appears to 
be still necessary to insist that it is a definite disease and not 
a “‘ rubbish heap ”’. 

Etiology.—The incidence of the malady is much higher in men 
than in women and it usually makes its appearance shortly 
after the person leaves school—that is to say, during adolescence. 
Neurasthenia used to be classed as a neurosis because, being 
ascribed to masturbation, its cause was supposed to be more or 
less contemporaneous with the disease. In my experience, how- 


ever, many neurasthenics (the most severe cases) are incapable 
224 


NEURASTHENIA 225 


of masturbation or, for that matter, of any other variety of 
sexual gratification. In fact, masturbation has been more or 
less successfully repressed and the disorder is traceable to re- 
pressed auto-erotism. Now auto-erotism is an infantile trend, 
therefore neurasthenia must be regarded as originating in an 
infantile fixation. It must accordingly be classed as a psycho- 
neurosis. 

It is true that masturbation and sexual excess sometimes 
cause a transitory state of nervous exhaustion closely resembling 
neurasthenia in some people, but this should not be labelled 
neurasthenia’”’, but rather ‘exhaustion neurosis’’. Most 
masturbators appear to suffer little or no ill effects from the 
practice. On the other hand it must be acknowledged that 
neurasthenics are especially hable to a short period of nervous 
exhaustion following attempted coitus or, to a smaller degree, 
masturbation. Ferenczi has called this condition “ one-day 
neurasthenia ’’. In some patients this state of exhaustion does 
not occur until the third or fourth day after the sexual act. 

Symptoms.—When the patient comes under observation there 
is always a history of previous masturbation and of loss of 
weight. 

There is complaint of general malaise and of never feeling 
well. On inquiry after their health, patients commonly reply 
that they “‘ don’t feel very grand’’. The complexion is pale 
and there is usually a slight chlorosis, the eyelids droop, the 
skin is moister than natural and the palms of the hands are 
bathed in sweat. 

Examination of the chest and abdomen reveals nothing 
abnormal except one curious and almost constant feature, a 
“ throbbing abdominal aorta’ of which no explanation is forth- 
coming. The pulsation of the abdominal aorta is such that it 
feels as if the artery were immediately beneath the skin. 

On examination of the nervous system there is found to be 
no loss of sensation nor is there any general cutaneous hyper- 
esthesia. Isolated spots of hyperesthesia may sometimes be 
detected. These are commonly situated along the spine and 
in the submammary, epigastric and ovarian regions. The testicle 
is also tender in some cases while others complain of a pricking 
pain in the neighbourhood of the prostate. Not uncommonly 
there is hyperesthesia in other sense departments. The patients 
cannot tolerate a bright light, and noises which are tolerable 
to an ordinary individual irritate them. They are especially 
annoyed by crowing cocks and the rumble of traffic. They are 

ee 


ce 


226 MIND AND ITS DISORDERS 


particularly sensitive to cold, usually have cold feet and wear 
abnormally thick clothing. 

The patients complain of all sorts of pains and other sensations 
for which no physical basis can be discovered. Specks appear 
before the eyes; the head feels numb or empty; there is a sense 
of pressure on the vertex or a feeling as if a cap were fitted tightly 
over it (symbolically representing psychical repression). In 
other cases there is actual aching at the top and back of the 
head, but this is unusual. Many patients complain of a 
“screwy ’”’ or “‘ crawling ’’ sensation in the neighbourhood of the 
occipital protuberance; one patient said that it felt as if a beetle 
were lying on its back inside the skull and kicking. Pain at 
the back of the neck is a common feature. 

Indigestion is a frequent complaint, but investigation asaalie 
proves that this is merely epigastric discomfort having no relation 
to mealtime, and the appetite is good. Sensations of weight and 
of pain sometimes occur in the legs. 

There is no disturbance of perception or ideation and hallu- 
cinations do not occur, unless the sensations above described 
are to be regarded as hallucinations. The memory and judg- 
ment are good and the patients have a remarkably clear insight 
into their wretched condition. 

The emotional tone is usually one of depression, but some 
patients become resigned and succeed in maintaining at least 
an outward show of cheerfulness. In the depressed cases 
emotional reaction is liable to be excessive; tears are frequent 
and the patient may even throw himself on his bed and in 
anguish bury his face in his hands. In a few of these cases 
attempts at suicide are made. 

Some of the patients are apt to be moody, irritable, aggressive 
and quarrelsome; they are exacting in their demands and take 
pleasure in giving trouble to others. Such symptoms are usually 
related to constipation and unconscious anal erotism. 

Distractibility is a marked feature. By this is meant that, 
while voluntary attention is with difficulty maintained, instinc- 
tive attention is easily aroused. The result is that the attention 
is constantly wandering and the patients are forgetful. The 
cause of the difficulty of voluntary attention is that it is accom- 
panied by an increased sense of effort and therefore of fatigue. 

This brings us to one of the main features of neurasthenia— 
viz., defect of volition. The patients are anxious enough to be 
busy about their affairs like other people; but all effort, mental 
or physical, leads to an intense feeling of fatigue. In many 


SYMPTOMS OF NEURASTHENIA 227 


cases even the thought of doing anything causes the patient to 
tremble and to break into a profuse perspiration (ergophobia). 
Hence he lies in bed day after day, week after week and month 
after month; but this prolonged’rest does not, at least by itself, 
relieve the condition, nor is any benefit obtained by attempting 
to fight the disease by working in spite of the fatigue induced. 

The beneficial effect of practice in making the subsequent per- 

formance of any particular action easier 1s wanting in neuras- 
thenia. This symptom is best shown by Weygandt’s method. 
The patient is given a sheet of paper with columns of figures to 
be added. He starts on the first column and at the end of a 
minute writes down his result so far as he has gone. Then he 
passes to the next column, adds for one minute and puts down 
the result as before, and so on through the whole series. Ina 
normal person, at first the effect of practice is noticeable in that 
the added portions of the columns get longer and longer until, 
fatigue setting in, they begin to grow shorter and shorter. In the 
neurasthenic, on the other hand, the added portions shorten 
from the very first. Mistakes in the addition also occur earlier 
than in a normal individual. 
_ Similarly, examination with the ergograph reveals that mus- 
cular fatigue sets in early, although the records of the first few 
contractions reach an average height. A special exemplification 
of this muscular fatigue is the so-called “‘irritable eye’, the 
patient complaining that the eyes ache on reading for a short _ 
time, although no error of refraction is to be found. Examination 
with the perimeter soon fatigues the retina, and unless carried 
out quickly, the visual field will be found contracted. 

Sleep is as a rule fairly good and there is difficulty in waking 
in the morning, although insomnia occurs in some cases, especially 
during the early hours of the night. Nocturnal emissions are a 
frequent complaint and a source of much worry to the patient. 
Spermatorrhcea occurs also during the day in some cases. As 
already stated, many neurasthenics are impotent or, more fre- 
quently, suffer from a severe exacerbation of their symptoms for 
some days after attempted coitus. Ejaculatis precox is the rule. 

The deep reflexes are usually increased. A peculiar feature 
of the knee-jerk, which is excessive, is that its elicitation com- 
monly causes the patient “to start’’, and sometimes even 
induces a sharp sensation in the back. 

The urine is to be regarded as normal, since some doubt 
has been cast upon the statements that the quantity of urea is 
diminished and that of the uric and phosphoric acids increased. 


228 MIND AND ITS DISORDERS 


Diagnosis.—There is a great tendency nowadays, even on the 


” 


part of many experienced physicians, to label as “‘ neurasthenia 
all functional nervous disorders which for the moment cannot 
be pigeon-holed. Doubtless this is partly due to inaccurate 


descriptions of the disease which appear from time to time. . 


In one description which I have before me, I note that some 
cases are said to drift into melancholia, others are patients with 
obsessional insanity suffering from morbid fears such as claustro- 
phobia and agoraphobia. I have even seen it stated that 
general paralysis may begin as neurasthenia; this is using the 
term as a Cloak for erroneous diagnosis. I need hardly say that 
these are not cases of the neurasthenia here described. Under 
these circumstances it behoves us to be very careful in the 
diagnosis of neurasthenia to exclude all those forms of disease 
which are liable to be mistaken for it; not that the diagnosis is to 
be arrived at merely by a process of exclusion, for neurasthenia 
is a definite disease with definite symptoms. If, however, care 
be exercised in the diagnosis, it will be found that it is less 
common than is usually supposed. 

Chronic nervous exhaustion is the disease which most closely 
resembles neurasthenia, so closely indeed that it has received 
the name of ‘acquired neurasthenia’’. Chronic nervous 
exhaustion differs in being a disease of middle life, usually 
traceable to some exhausting influence on the nervous system. 
The War was responsible for many cases of this type which were 
erroneously labelled “‘neurasthenia’’ for political reasons. 
The other essential difference is that peripheral analgesia is 
present in chronic nervous exhaustion, at least in the earlier 
stages. 

Hysteria is often mistaken for neurasthenia, so much so that 
hysteria due to traumatism is often called “‘ traumatic neuras- 
thenia’’. Localized anesthesia and paralysis do not occur in 
uncomplicated neurasthenia. I hope that the chapter on 
hysteria will convince the reader that there is not the least 
resemblance between the two diseases. 

Melancholia, especially the hypochondriacal form, is sometimes 
mistaken for neurasthenia. Such an error is avoided by atten- 
tion to detail. Melancholia begins more acutely, and usually 
at a later period of life than neurasthenia. The neurasthenic 
does not present the characteristic attitude of the ede cholidtl 
there is no rigidity, and the small brisk knee-jerks of melancholia 
contrast strikingly with the extensive knee-jerk of neurasthenia. 
Lastly, the hypochondriacal melancholiac suffers from delusions 


DIAGNOSIS OF NEURASTHENIA 229 


about his health and has no clear insight into the nature of his 
malady like the neurasthenic. 

Hypochondnacal paranoia begins much later in life than 
neurasthenia, and the patients, like the melancholiacs, suffer 
from delusions and have no clear insight; nor have they the 
fatigue symptoms of the neurasthenic. 

In any case of persistent headache the physician should always 
be careful to exclude the existence of organic intracranial disease 
before diagnosing neurasthenia. The optic discs should always 
be examined for neuritis. Differences between the reflexes of 
the two sides should put the medical man on his guard. 

The early stages of general paralysis and tabes dorsalis some- 
times exhibit a superficial resemblance to neurasthenia. Careful 
examination of the light reflex and due consideration of the age 
of the patient are the most important points in the diagnosis. 

Osler stated that exophthalmic goitre may in its early stages 
resemble neurasthenia. We ought therefore to examine all 
suspected cases of neurasthenia for tremor, tachycardia and 
enlargement of the thyroid body. 

Lastly, it must be insisted that a careful systematic examina- 
‘tion of all the organs of the body should be made, so as to be sure 
that the nervous disorder is not secondary to such conditions as 
gastric catarrh, phthisis, anemia or any other such organic disease. 

Prognosis.—This is entirely governed by the treatment, with- 
out which a neurasthenic cannot recover. He may have his 
good days as well as his bad, but any attempt to do a day’s work 
is sure to be followed by a relapse. Some of these patients 
develop paranoia in after years. Indeed paranoid symptoms 
frequently manifest themselves during the psycho-analytic treat- 
ment of even early cases. 

Treatment.—There is only one certain cure for neurasthenia— 
viz., psycho-analysis; but, inasmuch as most neurasthenics 
cannot afford this mode of treatment, can anything else be done 
to ameliorate their condition ? The answer is definitely “‘ No !”’ 
In spite of the multiplicity of wonderful formule recommended 
by manufacturing chemists for neurasthenia, not one of them is 
of the slightest use; and if some day some mitigating drug should 
be discovered, it should not be prescribed because these patients 
would soon become slaves to it. 

Neurasthenics should be advised to avoid becoming vale- 
tudinarians, npt to give way to their symptoms, but to continue 
work (or play) in spite of its fatiguing effect. Otherwise, the 
malady is sure to go from bad to worse. 


CHA PRE heave 
HYSTERIA, 


IN a previous edition of this work the hypothesis of Babinski 
was adopted—that hysteria is a disorder which arises as the 
result of suggestion, but further psychological investigation has 
shown this view to be at least incomplete; it will therefore not 
be mentioned further in this edition, despite the acknowledged 
fact that an hysterical symptom can frequently be both pro- 
duced and cured by suggestion or persuasion with or without 
hypnosis. 

Janet’s conception is that hysteria is ““a form of mental 
depression characterized by restriction of the field of personal 
consciousness, and a tendency to dissociation and emancipation 
of the systems of ideas and functions that constitute personality. 
Hence there is a tendency to complete division of the personality, 
and subconscious mental conditions grow and form a kind of 
, second personality ’’. This view is that the patient is in a state 

of absentmindedness, a sort of amnesia. 

Since Janet enunciated this hypothesis, psycho-analytic in- 
vestigation of hysterical patients has shown it to be correct; 
but it has carried us a step further than Janet. We have seen 
that a division of the personality exists in everybody, and Freud 
has shown that the hysterical symptom represents in symbolic 
form a compromise between an unconscious wish and its con- 
scious inhibition or repression. For example, an Englishwoman 
married to a German, who had been interned, was told by him 
that, after the War, she would have to go with him to Germany 
and to live there with him. Asa result she developed hysterical 
paraplegia, symbolizing that she could not “go’’. The para- 
plegia was a compromise which satisfied both conditions; her 
unconscious desire to “‘ go with’’ her husband was inhibited by 
her conscious desire to remain in England, but her paraplegia 
satisfied both conditions, for it excused her from “ going with ”’ 
her husband and also from going away from her native country. 

Etiology.—It sometimes happens that hysteria occurs in 
epidemic form. The “‘ dancing mania’’ of the Middle Ages, 


230 


ETIOLOGY OF HYSTERIA ZL 


which sometimes spread through enormous tracts of European 
territory, is probably the best example of this; but it is also 
occasionally seen to-day in divers forms in schools, nunneries and ~ 
remote villages. Such cases bring home to us the fact that there 
is but little difference between the unconscious desires of every 
one of us, and that we all have the same desire to repress them. 
When any individual of a community exhibits symptoms which 
would effect a compromise between his two personalities, what 
is more natural than that other members of that community, 
whose conditions are precisely the same, should develop the 
same symptoms? It must be admitted that there is an element 
of suggestion in these epidemics, but it plays a minor rdéle. 

Apart from epidemic influence, superstition and religious 
excitement must be regarded as etiological factors. Practical 
experience teaches that those who dabble with spiritualism, 
theosophy and allied subjects are especially liable to hysterical 
manifestations. Moreover, it becomes obvious why they should 
do so; for untrained, unscientific conscious attention to the 
phenomena of the unconscious tends to bring the conscious and 
the unconscious into conflict. Even psycho-analysis is dangerous 
' in untrained hands. 

The direct exciting cause of an attack of hysteria is usually 
some fright, shock or disappointment, not necessarily so severe 
that it would make a profound impression on anybody, but of 
such a nature that it provokes an abnormal reaction in the 
very patient under investigation, because of his special experi- 
ences of an earlier date, perhaps of childhood. 

Traumatism, especially to the spine, appears to be peculiarly 
liable to induce an attack of hysteria and it is particularly potent 
when the question of compensation hangs in the balance (under 
the Employers’ Liability Act, for example). Indeed recovery 
is not to be expected in these cases, even with good treatment, 
until the matter of compensation has been definitely settled one 
way or the other. This observation has led many to regard 
traumatic hysteria (‘‘ traumatic neurasthenia’’ as it used to be 
called) as nothing more than malingering. The War has produced 
thousands of these cases of traumatic hysteria and helped to 
eradicate the notion that the disease is a sham. The converts 
do not, however, accept the teaching of those who have made a 
special study of the neuroses, but attempt to treat such patients 
on the supposition that “ shell-shock”’ (as it has been named) 
is a neurosis Closely allied to malingering. 

Our soldiers at the front were all exposed to much the same 


232 MIND AND ITS DISORDERS 


conditions, but only a relatively small number suffered from 


traumatic hysteria, a fact which indicates that there is yet another © 


etiological factor in these cases. This is the already existing 
mental state of the soldier whose nervous system succumbs to 
his war experiences without actual injury. Investigation has 
shown that the particular circumstances which determine the 
hysterical symptoms usually possess a symbolic value for the 
patient owing to pre-existing worries, usually of a domestic 
nature and often of remote date, which he has wished and 
attempted to put out of his mind, perhaps so successfully that 
they have become unconscious. 

In all disease there is a certain amount of reciprocity between 
the predisposing and exciting causes. So it is with hysteria. 
With great predisposition an apparently trifling incident may be 
sufficient to bring a train of hysterical symptoms into existence, 
and wice versa. Now by far the majority of our soldiers who 
suffered from ‘“‘ war shock’”’ were but little predisposed to a 
psychoneurosis, but they were exposed to such extraordinarily 
trying conditions in the Great War that the influence of the 
exciting cause was overwhelming. For this reason it was seldom 


necessary to penetrate very deeply into the unconscious minds .- 


of these military patients in order to cure them. 

It is a remarkable fact that the ancients, in giving a name 
to this disease, should have selected one of sexual significance 
(Uorépa=the womb). According to their pathology hysteria 
was caused by the uterus wandering over the body away from 
its proper site, and they used to give valerian to drive it back 
again.* Now in the light of psycho-analytic revelations we find 
that they were bordering on the truth, and it is easy to see why; 
for their primitive mode of thought was more closely allied to 
our unconscious than the conscious thinking of modern civilized 
people. The hysterical symptom is not due to the presence of 
the uterus in the affected part, but it 7s due to a conscious refusal 
to give the sexual instinct its proper place, with the result that 
some non-sexual part of the body symbolically acquires a sexual 
valuation. Symbolically the uterus does leave its normal position 
and wander to other parts of the body. 

It is still more remarkable that the valerian myth should have 
persisted even to the present day; for surely no medical man 
in his Holy of holies really believes that he ever cured a true 
hysteria with valerian pharmaceutically. We may concede that 


* The sexual stimulant effect of valerian upon some of the lower animals 
is well known, 


CONVERSION HYSTERIA pias! 


it has a suggestive value; but this is psychotherapy, not pharma- 
cology. Those who still regard hysteria as a variety of malinger- 
ing tacitly admit this when they give valerian as a sort of veiled 
punishment; but pharmacological rationalization appears to have 
gone mad when we read of such drugs as valerianic diethyl-amide 
and bornyl-iso-valeryl glycocollate. 

Symptoms.—Hysteria may disclose itself in either mental or 
physical guise. In the latter case it is known as conversion 
hysteria, because the mental compromise is effected through 
physical manifestations or symptoms; in mental garb it is called 
anxiety hysteria, because the characteristic phenomena are mainly 
those of anxiety or fear. There are mixed cases, to be sure, 
and those in which one or the other group of symptoms slightly 
preponderates; but this is a matter of little practical import 
provided that the diagnosis of hysteria is correct for the particular 
patient presenting himself for treatment. 

The conception of hysteria above adopted precludes us from 
accepting as primary symptoms of the malady such phenomena 
as hemorrhage, oedema, skin eruptions, muscular wasting, anuria 
and fever. These might conceivably occur as secondary symp- 

‘toms; for example, hemorrhage frorn the mouth might occur as 
the result of some hysterical sucking movement. Or an hysteri- 
cal patient might induce some skin eruption for the purpose of 
increasing the interest taken in her case; but such an eruption 
would be a symptom of malingering rather than of hysteria.* 


Conversion Hysteria. 


Disorders of Sensation.—Of these perhaps the several varieties 
of anesthesia are the commonest. Hysterical hemianzsthesia is 
usually complete and extends to the middle line. It generally 
affects all the modes of sensation, pain, touch, heat and cold; 
but dissociation is not unknown. As a rule, the special senses 
of the same side are also involved—viz., hearing, smell, taste and 
vision (blindness of one eye, not commonly hemianopia). 

It can be demonstrated that the patient really does feel on 
the hemianesthetic side in some subconscious fashion by testing 

* Since writing the above I have had the opportunity of investigating 
psycho-analytically a case of lichen planus, whose etiology is usually—if 
not always—psychical. The case proved to be the fulfilment of an un- 
conscious wish for self-punishment (masochistic complex) for an unconscious 
father fixation (dEdipus complex) plus the fulfilment of a wish for syphilis 
(prostitution complex) symbolized by the lichen planus. 


Evans and Jelliffe (New York Med. Journ., December 2, 1916) have pub- 
lished a case of ‘‘ Psoriasis as an Hysterical Conversion Symbolization.”’ 


234 MIND AND ITS DISORDERS 


him in the following way: Tell him that you are going to touch 
him in various parts of the body and that he is to say “ Yes” 
when he feels it and ‘‘ No”’ when he does not feel it. In some 
cases the patient says ‘“‘ No’’ when touched upon the anesthetic 
side, clearly indicating that he does feel (Janet’s sign). Some- 
times too he may be awakened from sleep by pricking him on 
the anesthetic side. The anesthesia is usually of the left side 
(in right-handed patients). This is because the unconscious 
confuses “‘ right and left’ with “‘ right and wrong’’. Such loss 
of sensation therefore fulfils a desire not to feel or admit some 
desire which is “‘ wrong ’’. 

More limited areas of anesthesia may occur in the limbs, 
their characteristic being that they are ‘“‘segmental’’. The 
anesthesia reaches as high as the wrist, elbow or shoulder, or 
as high as the ankle, knee or hip on one or both sides. This 
anesthesia also affects all the modes of sensation as a rule; but 
here again dissociation is not unknown. The limit of the sen- 
sation is represented by a line drawn straight round the limb 
and there is no shading off: in these particulars, the anesthesia 
differs from that which I have described as occurring in states 
of exhaustion and in some forms of dementia preecox. “ Stock- 
ing ’’ and “ glove’ anesthesia occur similar to that found in some 
cases of peripheral neuritis; but there is this difference, that 
whereas the limit of the anesthesia in hysterical cases is the 
same for all forms of sensation, in peripheral neuritis there is 
dissociation at the margin, the loss of sensation for pain, heat 
and cold being more extensive than that for touch. Hysterical 
anesthesia never follows the distribution of a nerve or nerve-root. 

Subjective sensations of hysterical origin also occur, such as 
pain in the shoulder (diagnosed as rheumatism, by the way) 
symbolizing the burden the patient has to shoulder, stiffness at 
the back of the neck symbolizing “ stiffening one’s back”’ in 
opposition to difficulties, pruritus ani, pruritus vulve, vaginismus, 
dysmenorrhcea and some headaches, all of whose symbolism 
becomes clear on analysis. 

Blindness of one eye sometimes occurs independently of a 
general hemianesthesia, its hysterical nature being demonstrable 
by getting the patient to wear prismatic glasses of different 
angles in the two eyes, when he sees two objects instead of one. 
Hysterical hemianopia also occurs in some rare cases. The 
symbolism is obvious; owing to some unpleasant memory the 
patient does not wish to see on the hemianopic side. Blindness 
of both eyes commonly occurred during the War. Here, again, 


HYSTERICAL FITS 235 


the symbolism is obvious, for the patient has seen at the front 
such horrible sights that he wishes never to see again; and 
further psychical mechanisms are easily discovered by analysis. 

Various hyperesthetic areas, pains and abnormal sensations 
are common in the region of the trunk, usually on the /eft side. 
The ovarian and inguinal regions, the lower part of the breast, 
the shoulder and the spine, especially over the fifth and twelfth 
dorsal vertebre, are the parts most commonly found to be hyper- 
esthetic. ‘‘ Hysterical hip’’ and “hysterical shoulder ’’ have a 
striking resemblance to organic disease of these joints. Some 
patients complain of cardiac pain bearing a superficial resem- 
blance to angina. ‘‘ Globus hystericus’’ is a sense of fulness 
in the throat accompanied by a feeling of suffocation. Such 
symptoms always have a symbolic value. For example, Freud 
records a case in which “ globus hystericus’’ symbolized to the 
patient “I have to swallow that ’’—“ that’ being an insult by 
her husband. 

Disorders of Movement.—Of these, hysterical fits are the most 
important. The classical description includes two varieties, the 
“ hysteroid ’’ and the “‘ hystero-epileptic ’’. 

The hysteroid fit may be preceded by an aura of some simple 
kind, such as “ globus hystericus ”’ or epigastric sensation, lasting 
from a few seconds to a few minutes. The patient then falls 
to the ground, but in such a place and manner as to avoid injury 
to herself. Rigidity supervenes in which the back is arched so 
that the patient rests on her heels and occiput only. The arms 
are extended and the fists clenched with the thumbs outside 
the fingers or protruding between the index and middle fingers. 
This condition lasts from five minutes to an hour or more; the 
tongue is not bitten or the urine voided as in epilepsy. The 
eyelids are tightly closed and any attempt to open them induces 
yet firmer contraction of the orbiculares. This is likely to 
mislead the physician into the belief that the patient is malinger- 
ing, but such is not the case; the increased contraction is to be 
regarded as an unconscious reflex action. If the eyelids can be 
separated it will be found that the eyeballs are rolled upward 
so that the pupils can only be examined with difficulty. When 
this is possible, however, it is found that the reaction to light 
is preserved. The conjunctival reflex is also present. The fits 
may often be arrested by the application of some strong sensory 
stimulus such as the electrical wire-brush, pressure over the 
supra-orbital nerves or in the ovarian region. After a fit is 
over, the patient on being questioned states that she knows 


236 MIND AND ITS DISORDERS 


nothing about it; and there is no reason why she should be 
disbelieved, for the statements of various patients are in perfect 
accord with one another. The fits are sometimes preceded by a 
definite epileptic attack; an unobserved attack of minor epilepsy 
ushers in a hysteroid fit probably more often than is usually 
suspected. This view is supported by the beneficial effect of the 
bromides in some of these cases. On the other hand, we meet 
with cases in which convulsions occur, exactly like true epileptic 
fits in every particular, which are really hysterical. Such cases 
may be diagnosed from true epilepsy by the coexistence of other 
hysterical symptoms and by psycho-analytic investigation which 
of course dispels them if they are hysterical. 

The hystero-epileptic fit, which is seldom observed in a patient 
of British origin, almost invariably begins with an attack of an 
epileptic character. Then follows an extreme form of opistho- 
tonos in which the patient rests on the soles of the feet and top 
of the head. After a pause the trunk is violently thrown back 
on the bed: and this movement, rapidly alternating with opistho- 
tonos, throws the patient up into the air many times in rapid 
succession (‘‘ grandes mouvements”’ of the French). There 
now follows a stage in which the patient strikes many 
emotional attitudes illustrating joy, grief, terror etc. The 
terminal stage is one of delirium in which many hallucina- 
tions of vision are experienced. Of all this remarkable 
display the patient remembers nothing except perhaps some 
of the hallucinations. The ocular reflexes are retained as in 
the hysteroid fit and the knee-jerk is present throughout in both 
forms. 

Hysterical fits are followed by a copious flow of watery urine. 
This phenomenon is to be regarded as analogous to the increased 
flow which occurs in certain emotional states, such as fear. It 
is presumably due either to dilatation of the arterioles of the 
kidney or to a rise in the general blood-pressure, resulting from 
contraction of other arterioles. 

Hysteria sometimes makes its appearance in the form of more 
or less rhythmical spasms, the affected part of the body varying 
in different patients. We meet with jumping arms and legs, 
blinking eyebrows, salaams, hurried respirations, cough, hic- 
cough, sniffs, grunts, barks and other strange noises difficult of 
description. Such movements are commonly called “tics”’. 
They are extraordinarily common and Dr. S. A. K. Wilson has 
published a translation of a fair-sized volume on this subject 
alone by Meige and Feindel. It iscalled ‘‘ Tics and their Treat- 


y LO ee 


HYSTERICAL PARALYSES 237 


ment ’’ and is well worth perusal to-day, although it was written 
in the pre-psycho-analytic era. 

Catalepsy (flexibilitas cerea) sometimes occurs as an hysterical 
symptom and somnambulism is, with some justice, regarded by 
the French school as an hysterical manifestation. I have ob- 
served spasmodic convergent strabismus in quite a number of 
hysterical patients. 

Hemiplegia is not very common, but it occurs. It is usually 
associated with hysterical hemianesthesia. 

Hysterical paraplegia occurs in several forms. When asso- 
ciated with anesthesia of the legs, it is usually of the flaccid 
variety. In other cases the legs are rigid (hysterical contracture). 
In cases of the latter class of many years’ duration fibrous 
adhesions may occur in the joints. The knee-jerks are greatly 
increased and there may be spurious ankle-clonus. By spurious 
ankle-clonus I mean a non-persistent clonus of which the first 
contraction is an extension of the ankle pushing against the 
physician’s hand, the first contraction of a true organic clonus 
being an active dorsi-flexion of the ankle. Another feature of 
spurious Clonus is that it cannot be elicited by tapping the tendo 
-Achillis put on the stretch, whereas true clonus can be induced 
this way. The plantar reflexes are absent. 

Some patients are able to use all the muscles of the legs per- 
fectly while lying in bed, but they cannot use them for standing 
or walking (astasia-abasia). Astasia usually symbolizes an 
unconscious desire ‘‘ to fall’’ in some sense, perhaps morally, 
and abasia represents an inability “to go’’ in some sense—as 
in the case quoted on p. 230. 

Monoplegia or paralysis of one arm or leg, usually associated 
with flaccidity and anesthesia, is another common manifestation 
of hysteria. The paralysis is usually complete and it does not 
involve any muscles of the trunk; such a condition cannot be 
referred to an organic lesion. 

The commonest hysterical affection of speech is “‘ stammer- 
ing’’. This is sometimes consciously associated with a “‘ stam- 
mering bladder’’ (in micturition), and we find on psycho- 
analytical investigation that stammering is invariably associated 
with unconscious difficulties of micturition and the castration 
complex. The severest case I ever had (five words a minute) 
had the severest castration complex I ever encountered, which 
was traced to repeated stretching of the prepuce during the first 
two years of life before deciding on circumcision. Such remarks 
as “‘ It is too small”’ or “‘ It must be cut off’ have a profound 


ce 


238 MIND AND ITS DISORDERS 


effect on the child’s mind, and I mention the case to warn medical 
men against the practice of trying to stretch the prepuce instead 
of circumcising the child immediately the prepuce is found to 
be too constricted. 

Hysterical aphonia (loss of voice) is very common. It is a 
frequent accompaniment of a common cold, but it also occurs 
independently of this as the result of shocks, frights and other 
emotional disturbances. Hysterical mutism is a condition in 
which the patient is unable to speak at all; he cannot utter a 
single word, even feebly. 

In all these paralyses the superficial reflexes of the affected area 
are diminished orabsent. For example, the plantar reflex is usually 
absent in hysterical paraplegia and the pharyngeal reflex in 
hysterical aphonia, thus rendering laryngoscopic examination easy. 

The organic reflexes are sometimes affected in hysteria. Some 
patients suffer from difficulty of swallowing (dysphagia), others 
from uncontrollable vomiting, a condition which may end fatally. 
There is even an hysterical form of constipation, its peculiarity 
being that it is not relieved by aperients or enemata, the bowels 
being opened by suggestion only, and the constipation perma- 
nently cured by psycho-analytical interpretation. 

‘““ Spasmodic ’’ dysmenorrhoea and vicarious menstruation are 
always hysterical, and not uncommonly amenorrheea is of the 
same nature. 


Fixation Hysteria. 


Freud has given this name toa group of cases in which 
the site of hysterical manifestation is determined by predis- 
position of the affected part. If, for example, a person has 
previously suffered severe traumatism in one arm, that arm is 
lable to be selected as the site of subsequent hysterical symptoms. 
Similarly, an organ possessing for the particular patient excep- 
tional sexual value (for example, the eyes in the case of voyeurs 
or peepers) 1s especially prone to hysterical affection, usually 
blindness. It appears that, in this variety of hysteria, some 
particular part of the body is already prepared to meet the 
hysterical tendency half-way and to become, so to speak, the 
“cat’s-paw ’’. Many cases of traumatic hysteria belong here. 


Anxiety Hysteria. 


In this variety of hysteria mental symptoms predominate. 
The conversion symptoms most frequently associated with 
anxiety hysteria are, in my experience, headache, amenorrhea, 


ANXIETY HYSTERIA - 239 


spasmodic dysmenorrhcea and dilatation of the stomach, with 
or without visceroptosis and mobile kidney, but any of the 
physical disorders mentioned under the heading of the anxiety 
neurosis may occur. 

The characteristic mental attitude is one of apprehensiveness 
or anguish, so that many cases can easily be mistaken for melan- 
cholia, so much so that sometimes the diagnosis cannot be 
established until a preliminary psycho-analytical investigation 
has been made. In asylums there are many cases of anxiety 
hysteria which have been labelled “‘ melancholia ”’. 

With some patients the apprehensiveness is more localized, 
so to speak, and attached to specific situations. For example, 
they are overcome by a sense of fear or anguish in open spaces 
(agoraphobia), in confined spaces (claustrophobia), on heights 
(acrophobia) or in crowds. There are many other situations in 
which similar phobias may be induced, but it is convenient to 
consider them in greater detail in the ensuing chapter, although 
it must be admitted that most of the phobias belong here. Like 
the symptoms of conversion hysteria, they are a form of com- 
promise between unconscious wishes and corresponding repress- 
ing forces, more or less conscious, but the formation of a definite 
phobia appears to be a defence against conversion symptoms. 

Most cases of anxiety hysteria are associated with a dilated 
stomach. This is due to the adrenalemia of anxiety, which 
inhibits peristalsis and closes the pylorus. The resulting fer- 
mentation of the gastric contents leads to further dilatation and, 
in some long-standing cases, a skiagram shows that the greater 
curvature has dropped as low as the pelvis. Since the colon 
hangs from the stomach (except for the costo-colic ligament at 
the splenic flexure) the ascending and transverse colon drop too, 
the former dragging the right kidney out of its bed (“ floating ”’ 
or “‘mobile’’ kidney). The gastric dilatation gives rise to flatu- 
lence, and the visceroptosis causes backache. 

Mental Characteristics of Hysteria.—Since every hysterical 
symptom is the gratification of some unconscious wish or wishes 
it is not surprising to find that the hysterical patient commonly 
likes to cling to her symptoms and offers a very strong resistance 
against recovery. There are all sorts of reasons why the doctor’s 
advice should not be followed. The sounder the advice the 
stronger the resistance, for the unconscious knows well enough 
when it has met a real enemy. Symptoms occur at just that 
time and place when and where they are most inconvenient and 
will attract the greatest amount of attention; new symptoms are 


240 MIND AND ITS DISORDERS 


easily created by suggestion or by imitation of other patients 
and, when the mere fact of being ill suffices to calm the mental 
conflict, the patient resorts to self-mutilation of some kind or 
something very like malingering in order to meet the situation. 

A still more important characteristic of hysterical patients 
is that their emotional reaction is excessive for some situations 
and defective for others. They laugh and cry in the wrong 
place, so to speak. The phobias of anxiety hysteria are a good 
example of this condition. The patients fall into a state of 
dread in some quite commonplace situation which stands in 
their minds for some situation in which their fear, or a repressed 
desire which it replaces, would be well justified; whereas they 
remain unaffected and perhaps smile at a real danger. Take 
the case, for example, of a patient of mine who had such a 
morbid fear of stammering that he fell into a state of terror 
whenever he had to give an order to one of his men, although 
he had to be doing this all day long and every day for years. 
Fortunately he was able to conceal this symptom so that nobody 
had any suspicion that there was anything wrong with him; 
indeed it was the offer of promotion to a more responsible position 
which caused him to seek advice. On the other hand, this man 
was rather entertained by an air-raid. 

This peculiarity of hysterical patients is known as the “ trans- 
valuation of values’’. It is not confined to cases of anxiety 
hysteria, but is also a peculiarity of patients suffering from 
conversion hysteria. Everything about them has a personal 
interest and they become elated or, more frequently, take offence 
at trivialities. They are liable to outbursts of anger or sullenness 
and often refuse to state the reason for their behaviour. They 
are egoistic, ever on the look-out for sympathy from others, 
sympathy which feeds the disease, but which they take as their 
right; and if they find it not, they will exaggerate their symptoms 
and even make false statements in order to attract more attention 
to their case. 

Morbid Anatomy.—Lovell of Bethlem states that in anxiety 
states the range of surface tension of the blood serum is lowered. 
He correlates this observation with another, viz., that there is 
deficiency of pancreatic secretion and, moreover, that in cases 
of long duration there is a chronic inflammatory condition of the 
pancreas to be found post mortem. It would appear probable, 
seeing that the internal pancreatic secretion is the normal anti- 
dote to adrenalin, that these changes are in some way related to 
the adrenalemia constantly present in anxiety states, 


HYSTERICAL INSANITY 241 


Hysterical Insanity.—In some rare instances the above charac- 
teristics influence the patient’s conduct to such an extent that 
the authorities of hospitals and nursing-homes refuse to accept 
further responsibility in the treatment. Under such circum- 
stances the patient has to be removed to an institution for the 
insane where, if carefully treated, she usually makes a good 
recovery. Also, a few patients suffering from hysteria place 
themselves under asylum care as voluntary boarders and some 
of these subsequently have to be certified. 

For instance, definite mental derangement exists during the 
terminal stages of an hystero-epileptic fit and similar disorder 
sometimes occurs without any associated convulsion taking place. 

Such accesses occur in one of two forms: 


(a) Hallucinatory delirium. 
(5) Anterograde amnesia. 


Generally they constitute the fourth phase of an attack of 
hystero-epilepsy, but in some instances they may precede or 
replace a convulsion. 

In hallucinatory delirium the patient sees animals, visions of 
God (usually symbolizing the father) or emotional incidents of 
her past life. She is anesthetic except to the most powerful 
stimuli, but is to some extent capable of perceiving the nature 
of her surroundings. She weaves her hallucinations into them 
and lives in a world of her own, not uncommonly she is living 
over again some past emotional incident. As a rule there is an 
abnormal amount of activity, but the patient can usually be 
induced to recount what she sees. This dream state seldom 
lasts more than a few hours and when it is over the memory of 
it is usually incomplete. 

In the attacks of anterograde amnesia, to which Pitres applied 
the somewhat inelegant name “‘ecmnesia’’, the patient has 
complete loss of memory for all events after a certain date, often 
years back. As a consequence she thinks and acts as she did 
at the age to which she has temporarily returned. These attacks 
also rarely last more than a few hours. 

Prognosis.—It is probable that a small number of the milder 
cases of hysteria recover without treatment of any kind, but 
the prognosis generally depends on the treatment (q¢.v.).. In the 
great majority of cases the physician may look forward with 
hope to effecting in a few months a cure which, in view of the 
apparent severity of the symptoms, frequently causes much 


surprise to the friends. Unfortunately, however, hysteria has a 
16 


242 MIND AND ITS DISORDERS 


great tendency to relapse in home surroundings, but the tendency 
decreases with advancing age. The duration of the disease does 
not materially affect the prognosis provided there have not been 
previous serious attempts at treatment which have failed. A 
physician undertaking the treatment of a case of hysteria has 
a heavy responsibility; for, if he fails to cure his patient, he thus 
suggests that the case is incurable and makes subsequent attempts 
much more difficult; for hysterical patients are pre-eminently © 
suggestible. Consequently, if a patient has already been treated 
by neurologists and spent years in neurological hospitals, she 
might almost be regarded as incurable because the suggestion 
of incurability has been given in its most potent form. 
Previous treatment by hypnotism and suggestion is, for some 
reason or other, inimical to the success of subsequent treatment 
by psycho-analysis. 

It must not be forgotten that a few cases of hysteria end fatally, 
especially those suffering from dysphagia, anorexia and vomiting. 

Treatment.—Hysteria must be met on its own ground. As we 
have seen, it is a purely mental disease and only mental measures 
will cure it. Doubtless some very miid cases have been appar- 
ently cured by the administration of iron to anemic patients, 
of such appetizers as a mixture of nux vomica and nitrohydro- 
chloric acid in anorexia, or of cod-liver oil, extract of malt and 
such remedies when malnutrition is a marked symptom; but it 
is probable that recovery is effected more by the suggestive 
or mental effect of the medicines and their physical results than 
by specific therapeutic action. Moreover, we must not forget 
the mental influence of the doctor’s visits, especially if he is 
fortunate enough to have what is popularly known as “a good 
bedside manner ”’. 

Many years ago Weir Mitchell introduced his well-known 
method of treating patients by absolute rest in bed, isolation 
from the outside world, systematized overfeeding, general massage 
and faradic stimulation, with a view to increasing the patient’s 
nutrition and putting on weight, wherein it was and is most 
successful. Many patients recover from their hysterical symp- 
toms under the treatment. Unfortunately, however, the cure is 
but temporary in many cases. It used to be called the Weir 
Mitchell treatment by isolation, but is now popularly known as 
the ‘rest cure’’. The late Dr. Morton Prince, a pupil of Weir 
Mitchell, used to tell us that the originator of the “ rest cure ”’ 
clearly recognized that suggestion played an important role in 
the method. It now seems probable that this treatment is 


TREATMENT OF HYSTERIA 243 


nothing more than psychotherapy veiled by a complicated system 
of disguise, and that every item of it acts by suggestion only. 

Cognizance is taken of the fact that home influences are 
inimical to the cure of hysteria. The patient is therefore sent 
to a nursing-home, put to bed in a room by herself and allowed 
to see nobody but the doctor and nurses attending her. She is 
not allowed to do anything, not even to knit, sew or read, and 
she must neither write letters nor receive them, nor is she to be 
told any news from the outside world. The rest must be abso- 
lute. In some cases it is recommended that the patient be raised 
or lifted when necessary, as if she were helplessly paralyzed. 
Dr. Weir Mitchell even went so far as to suggest that a bed-pan 
should be used rather than a commode. 

The next aim in the treatment is increase in the patient's 
weight. This must be accomplished steadily and rapidly, so 
that, each week when the patient is weighed, she is impressed 
by the large amount of flesh she has put on. 

The feeding is important. At first the patient must be induced 
to eat a little more than has been her custom, together with a 
glass of milk after each meal. The quantity of food taken at 
‘each meal is then steadily and tactfully increased, extra glasses 
of milk being given in the middle of the morning and afternoon 
and at bedtime. Subsequently cream may be added, at first in 
small quantities, later as much as 2 ounces in each glass of milk. 
At the end of a month the patient should find herself taking four 
good nutritious meals every day as well as 3 to 4 pints of milk 
with 12 to 15 ounces of cream. 

The nutrition is further increased by general massage for 
twenty minutes, gradually extended to one hour, every morning 
during the first two weeks, subsequently for one hour morning 
and evening. The masseuse will naturally pay special attention 
to those parts of the body in which the hysterical symptoms are 
manifested. 

Lastly, electricity in some form suited to the particular case 
should be applied twice a day. For example, anesthetic parts 
should be treated with the faradic wire-brush, the current being 
of sufficient strength to penetrate the anesthesia at least in some 
small areas; disturbances of motility without anesthesia may 
be treated by judicious use of the ordinary electrodes; hysterical 
blindness by mild galvanic shocks applied to the closed eyelids, 
and so forth. 

Hydrotherapy is often useful as a subsidiary method of treat- 
ment in suitable cases, especially in the form of the cold shower 


244 MIND AND ITS DISORDERS 


and needle bath. In long-standing cases which have already 
undergone many attempts at cure, original devices for impressing 
the patient must be left to the ingenuity of the physician. 

The latter should devote his visits to discovering signs of 
improvement and letting the patient see them, without obtru- 
sively pointing them out. 

As recovery becomes established, massage, electricity, extra 


milk and the general. régime should be gradually dropped and _ 


the patient allowed to return to normal life while under the care 
of her nurses. Indeed it is well that she should go for a holiday 
with one of them as a prelude to her return home. 

It is best to avoid drugs; but it is, of course, necessary to 
regulate the action of the bowels and to see that the patient 
gets sufficient sleep. It is also sometimes desirable to give 
before meals an appetizer such as nitrohydrochloric acid com- 
bined with the tincture of nux vomica. The bromides are useful 
in the treatment of patients suffering from hysterical fits, for 
whom the general treatment of hysteria should be combined 
with that of epilepsy. 

Concealed suggestion may also be given by using some kind 
of device for beguiling the patient into recovery. For example, 
in a case of hysterical paralysis of one arm, a faradic battery may 
be used, one electrode of which is placed between the shoulders 
while the other is applied to the motor point of the biceps. The 
patient is then told to bend her elbow. As soon as she makes 
the effort the current is switched on so as to cause the biceps to 
contract and flex the elbow, while the doctor says, “‘ Look ! you 
are bending it—you see, you can do it—you will soon be cured ”’. 
The arm electrode is then moved to another motor point, to flex 
the fingers for example, and a similar procedure is carried out, 
and so on all over the arm. Some patients can be cured at a 
single sitting in this way. It must, of course, be left to the 
doctor’s ingenuity to plan a combination of wiles, artifice, device 
and manceuvre suited to the particular case he is treating. The 
method was used successfully in many cases of traumatic hysteria 
occurring among our soldiers during the War. 

To suggest recovery in the waking state, after the manner of 
Dubois and Déjérine, by demonstrating to the patient that he 
is not suffering from any organic disease and that his affliction 
is therefore purely mental, is not likely to achieve many good 
results; yet I suppose that these authors must have met with 
some success in view of the ponderous tomes they have written 
about the method. 


TREATMENT OF HYSTERIA 245 


Suggestion in the hypnotic state is quite another matter. 
Here the patient is in a much more receptive state of mind, and 
many cases can be cured, even at a single sitting, under light 
hypnosis. For example, a patient suffering from hysterical 
astasia-abasia may perhaps be induced to walk hypnotized and, 
if he be gradually awakened while he is still walking so that he 
can observe his capabilities for himself, he has already trodden 
the path towards recovery. Several further sittings may be 
necessary to complete the cure; and this applies also to the other 
modes of treatment above described. Even in the Weir Mitchell 
treatment the daily visit of the doctor is an important item. 

In any case suggestion consists of the imposing of the will of 
the physician on that of the patient, but there is no attempt to 
discover and eradicate the source of the mischief; hence we find 
that many cases which have been cured by one of the above 
methods relapse or develop new symptoms to replace the original 
one and to fulfil its purpose. 

The only radical cure for hysteria is to discover the unconscious 
strivings which have given nse to the disease and, in so doing, 
to reveal them to the patient. This procedure is none other than 
‘psycho-analysis, to which frequent reference has already been 
made. Its great disadvantage is that it takes an enormous 
amount of time, so that no great physician can afford to treat 
a patient by this method without more or less proportionate 
remuneration. For the poorer classes a lengthy psycho-analysis 
is therefore inapplicable; but the physician will always find his 
psycho-analytic knowledge, if acquired by experience and not 
only by reading, useful for helping such patients. 

Mainly owing to the enormous fees of nursing-homes, a six 
weeks’ “‘rest cure’’ is often as expensive as psycho-analysis. 
In fact, the expense is but one more item of suggestion in Weir 
Mitchell’s method. Moreover, this mode of treatment appeals 
to the patient and his friends because it is of comparatively 
short duration and gives the patient much less trouble. The 
main objection to it is that which to a conscientious physician 
is paramount—namely, that it is not a radical cure, while psycho- 
analysis is. The latter is not necessary in every case, and the 
best mode of treatment for any particular patient is to be decided 
from experience, to discuss which would disproportionately ex- 
pand this manual. 

Lovell claims to have cured anxiety states by administering 
secretogen in order to stimulate the pancreas. 


246 MIND AND ITS DISORDERS 


EXOPHTHALMIC GOITRE. 


This disease in its fully developed form is characterized by 
enlargement of the thyroid, protrusion of the eyes, tachycardia, 
palpitation, tremor and mental symptoms. , 

It isa variety of anxiety hysteria with protrusion of the eyeballs 
(exophthalmos) and enlargement of the thyroid superadded. 

Etiology.—Exophthalmic goitre is four times as frequent in | 
females as in males, and it occurs usually between the ages of 
sixteen and forty. It is rare before ten and after fifty, but 
Dreschfeld reported one case at the age of three and Divel 
another occurring as early as two and a half years of age. Not 
uncommonly it occurs in several members of the same family 
and in such cases it is usually found that one or other of the 
parents is neurotic or psychotic. The disease sometimes arises 
as a sequel to influenza; but far more frequently the exciting 
cause is found to be some mental shock such as fright, worry 
or grief. Pregnancy is sometimes the cause; on the other hand 
the symptoms are often ameliorated by the occurrence of preg- 
nancy. The disease may be associated with hysteria, epilepsy, 
chorea, and, as we shall see later, insanity. 

Although this disease so closely resembles the anxiety neurosis, 
as will be seen in the next section (which is exactly reproduced 
from the second edition, in which I classified it among diseases of 
the thyroid), it is rarely caused by exactly the same etiological 
conditions as those of the anxiety neurosis. The usual sequence 
of events appears to be (1) a fright, worry or anxiety induced 
by some incident or circumstances which symbolize sexual 
aggression; (2) partial or complete repression of the incident 
or circumstances, whereby the fear is left unattached and there- 
fore liable to attach itself to any transitory situation; (3) partial 
or complete repression of the fear, which then finds expression 
in the symptoms of exophthalmic goitre, which are nothing more 
than the physical accompaniments or, as I think, bases of fear. 

As examples I give a couple of juvenile cases, because they 
illustrate unconscious early sexual symbolism before the patient 
was in the least degree conscious of sexual matters or feelings. 

A female child aged seven developed exophthalmic goitre as 
the result of being frequently frightened by a black dog which 
lived in the same street. Associations revealed that the black 
dog symbolized a wicked man, “ black”’ meaning “‘ wicked ” 
and “‘dog’’ signifying ““man’’, “‘ animal passion”’ etc. She 
recovered. 


EXOPHTHALMIC GOITRE 247 


A girl of eleven, whose parents had died during her infancy, 
was warned by a surrogate father that she should always make 
sure, on retiring at night, that there was not a man under her bed. 
As a result she used to go to bed in terror every night, but the 
fear gradually extended into the day. At fifteen years of age 
this dread disappeared and became replaced by exophthalmic 
goitre or the physical signs of fear. It was the worst case I have 
ever seen; indeed, she died six months after the onset. 

Physical Signs.—The enlargement of the thyroid is as a rule 
moderate and does not in itself greatly inconvenience the patient. 
In some cases, however, it exerts some pressure on the trachea 
and gives rise to cough and even dyspneea. It is usually pulsa- 
tile; a thrill is sometimes to be felt in it and a hemic hum heard 
with the stethoscope. 

The eyehds are retracted, the palpebral fissure is widened 
and the eyes protrude. All this gives the patient a staring 
aspect. If, without moving the head, he transfers his gaze from 
the ceiling to the floor, the upper lid lags behind so that a portion 
of the sclerotic above the cornea becomes visible. Nictitation 
is diminished in frequency. Convergence is weak and in severe 
cases of exophthalmos there may be weakness of the external 
recti so that double vision results on extreme lateral deviation 
of the eyes. 

The frequency of the pulse is greatly increased. A pulse-rate 
of 120 per minute is common and this is easily raised to 140 by 
slight exertion or emotional disturbance; even 160 is not rare. 
Palpitation is a fairly constant symptom. Low blood-pressure 
is the rule and probably accounts for those cases in which the 
patient feels the pulse all over the body. 

There is fine tremor of the limbs and trunk. It is best seen 
in the fingers and especially when a good many muscles are put 
into action, as when the patient stands, holds out her hands 
and separates the fingers. 

The patients are thin and in severe cases extremely emaciated. 
They are weak and easily become fatigued on exertion, either 
mental or physical. 

The appetite is usually excessive. Often it is capricious, the 
patient desiring to eat out-of-the-way, indigestible forms of food 
such as lobsters, pickles and nuts. The saliva is scanty and 
viscid and there is insatiable thirst. In some cases, on the other 
hand, there is loss of appetite. 

Diarrhoea and vomiting are common symptoms. These may 
occur either together or independently of one another. Dresch- 


248 MIND AND ITS DISORDERS 


feld has shown that the vomiting of exophthalmic goitre is 
associated with acetonzemia, acetonuria and air-hunger, such as 
we see in diabetes. Asa rule the urine is otherwise normal. 

It has been demonstrated of late that the basal metabolic 
rate is enormously increased in all cases of this disease. 

The patients feel hot and wear a minimum amount of clothing 
even in winter. The secretion of sweat is increased and the 
moisture of the skin thus caused diminishes its electrical resis- 
tance, so that the muscles respond more readily to electrical 
stimulation than in the normal individual. The knee-jerks are 
brisk. 

A good many “incomplete ’’ cases occur in which either the 
thyroid enlargement or exophthalmos is wanting. 

Mental Symptoms.—It has been pointed out by certain writers 
that the above series of physical signs of exophthalmic goitre 
is exactly the same as occurs in a normal person experiencing 
the emotion of fear. This is the keynote to the mental symptoms 
of the disease. Indeed, a well-known general physician of much 
experience, who did not know my views respecting exophthalmic 
goitre, once remarked to me, I think jocularly, that he had 
noticed that nearly all the occupants of a tramcar during an air- 
raid suffered from exophthalmic goitre. 

A short period of irritability and restlessness usually precedes 
the development of the physical signs and when these become 
pronounced the patients are in a constant state of dread. As 
every experienced hospital nurse is aware, any unusual incident 
occurring in the ward, however trivial, even the placing of screens 
round another patient’s bed, serves as a point d’apput for alarm. 
When they receive a letter they fear that it may contain bad 
news. Sometimes they are afraid that in telling the truth they 
may bring some harm upon themselves or their family, and 
they become untruthful. In other cases this fear leads to a 
suspicious habit of thought. Their sleep is disturbed and they 
are liable to wake up in a fright. 

Sensation, perception and ideation are as a rule unaffected; 
but hallucinations, usually visual, occur in a few cases. The 
train of thought, judgment and reasoning are all normal and 
the memory is good. The attention is apt to wander. The 
patients are usually rather wilful; but their general conduct, 
except in so far as it 1s influenced by the prevailing affective tone, 
may be regarded as normal. 

The above description refers to the ordinary mental state of 
a patient suffering from exophthalmic goitre; but it has been 


EXOPHTHALMIC GOITRE 249 


long recognized that other psychoses are especially liable to arise 
in the course of this disease. 

Episodic Mental Disorders.—It is not surprising to find that 
morbid fears and associated impulses are common among the 
episodic mental disorders occurring in the course of exophthalmic 
goitre. They differ from the obsessions described in the chapter 
on the compulsion neurosis in that they are more variable. There 
is no persistent agoraphobia; the morbid fear is liable to change 
its character in the course of time, for example, to acrophobia, 
fear of knives and so forth. 

Mania and melancholia are also liable to complicate exoph- 
thalmic goitre, the former being the more frequent, perhaps on 
account of the diminished blood-pressure. Both states tend to 
terminate in secondary delusional insanity, the patient develop- 
ing delusions of persecution. I have also met with true paranoia, 
tics, hysteria and hystero-epilepsy. 

Morbid Anatomy and Pathology.—No changes of importance, 
such as might suggest an unequivocal physical basis of this 
disorder, have been discovered in the central nervous system. 
Dr. W. S. Greenfield described changes in the sympathetic 
‘ganglia of the neck, but these are not regarded as peculiar to 
exophthalmic goitre. | 

The thyroid is enlarged and unduly soft and it may contain 
small cysts of colloid material. Microscopically it is found that 
the secreting membrane lining the alveoli is hypertrophied and 
thrown into folds and consists of columnar instead of cubical 
cells. In conformity with this change the contents of the alveoli 
contain mucin as well as colloid material. There is a deficiency 
of iodine in the gland. In long-standing cases it becomes hard 
and fibrous (toxic adenoma). 

The thymus gland is hypertrophied, but normal in structure, 
and occasionally it causes dyspnecea. 

It has been suggested that the symptoms might be explained 
by overactivity of the thyroid gland and consequent excessive 
production of its internal secretion; but the disease cannot be 
produced in most people by the ingestion of large doses of the 
dried gland, although Boinet has recorded one case in which the 
disease was caused in this way on two separate occasions and 
was accompanied by mental symptoms (Rev. Neurolog., 1899). 
It is not stated and probably not known whether the thymus 
was enlarged in this patient. 

Many of the symptoms, but not all (the tremor, for example), 
can be explained on the supposition that there is excitation of 


250 MIND AND ITS DISORDERS 


the sympathetic system. This and many other considerations 
rather support the view that this disease is purely psychical in 
origin. 

Prognosis.—Exophthalmic goitre has so many possibilities 
that we have to be extremely guarded in our prognosis. Its 
duration may be anything from a few days to twenty years or 
more. On the whole the tendency is towards recovery, but 
about 25 per cent. of the cases terminate fatally. The prognosis 
respecting both recovery and the expectation of life is rather 
more grave when episodic mental disorder supervenes. Of forty- 
three such cases collected by Hirschl, only six recovered from 
the mental disorder. Some cases terminate in myxcedema, even 
after so short a period as two years. The possibility of inter- 
current disease must not be forgotten; many of these patients 
die of phthisis. 

Treatment.—Almost every form of treatment has been tried 
for exophthalmic goitre; each has had its successes and failures. 
For some years the serum or milk of goats which have had their 
thyroid gland removed has been successfully employed and 
partial thyroidectomy has proved valuable in some early cases. 
More recently the application of X-rays to the thymus has found 
favour. Partial thyroidectomy and X-ray treatment relieve 
practically all the physical manifestations, but they do not 
entirely alleviate the mental symptoms, sometimes not at all. 
One of the most striking results of the thyroidectomy is the 
immediate reduction of the basal metabolic rate to normal. If 
X-ray treatment gives no promise at the end of one month it 
should be discontinued. Older remedies are the internal ad- 
ministration of arsenic and painting the skin over the thyroid 
with iodine. 

The administration of small doses of iodine, either in the form 
of potassium iodide (not more than I grain per diem) or Lugol's 
solution (not more than 5 minims a day unless the patient is 
under constant medical supervision) affords great amelioration; 
but this is only temporary and the medicine is usually given for 
three weeks in order to prepare the patient for operation. 

The patient should live in good hygienic surroundings, prefer- 
ably in the country. Mountain air is said to do good to some 
patients. A liberal, plain, nutritious diet should be allowed. It 
may be augmented by milk and cream and supplemented by 
the administration of cod-liver oil and extract of malt. Bella- 
donna proves to be the most serviceable sedative. Complica- 
tions are to be treated on general medical principles. 


EXOPHTHALMIC GOITRE 251 


It must not be forgotten that these patients are easily fatigued 
and that exercise is to be discouraged. est in bed is to be 
enjoined during acute exacerbations of the disease. 

Psycho-analysis reduces the pulse-rate practically to normal 
in a month or six weeks, and the other symptoms are gradually 
ameliorated in a few months; but my experience of this treat- 
ment of exophthalmic goitre is at present too limited to justify 
the suggestion that all other modes of treatment should be 
scrapped in its favour. All my psycho-analytic cases occurred 
during the War and the analysis had invariably to be given up 
because the patients could not stand the air-raids on London 
and went to live in country districts. I can confidently assert, 
however, that so far its results were remarkably promising. 

That the surgical procedure now in vogue (thyroidectomy) is 
not always necessary is proved by the fact that a considerable 
number of these cases recover spontaneously, just as other mild 
hysterical cases do. 


CHAPTER VI: 
THE OBSESSIONAL NEUROSIS. 


IRREPRESSIBLE THOUGHTS, FEARS AND IMPULSES. 


‘ , 


THE name “ psychasthenia’’ was formerly applied to the con- 
dition here described; but, since it has been used to include a 
large number of symptoms which do not belong here, especially 
by Janet and his followers, the name has been changed to “ the 
obsessional neurosis’ or “‘ the compulsion neurosis ”’. 

In the class of patients about to be considered the mental state 
is such that some particular thought, feeling or impulse is so 
uncontrollable and predominates to such a degree that it becomes 
a real annoyance to the person possessing it. 

This abnormal mental state is occasionally experienced by 
perfectly normal people. To take some of the most frequent 
examples: When we hear a catchy tune we instinctively sing 
it over several times “in our heads’’, but occasionally this 
process repeats itself over and over again in spite of every effort 
being made to put a stop to it, so that the tune “runs in the 
head ”’ for days or even weeks together. The same happens in 
the’ case of catchy rhymes, the classical example being Mark 
Twain’s 

“Punch, conductor, punch with care, 
Punch in the presence of the passengare.”’ 


It is instinctive in man to step over ditches, holes and such- 
like gaps when he is out walking; and a burlesque of this instinct 
takes place when he adjusts his steps to avoid walking on the 
cracks between paving-stones. If during this process he should 
by mischance happen to step on one of the cracks, he experiences 
a certain amount of dissatisfaction. Yet why should he ex- 
perience dissatisfaction when he knows perfectly well that it 
does not matter ? And why should he put himself to all this 
trouble when he well knows that it is unnecessary ? It is for 
no other reason than that he cannot help it. An irrepressible 


impulse was foiled. 
252 


OBSESSIONS 253 


The instinct of the preservation of property is probably 
responsible for a man getting up several times in the middle of 
the night in order to make sure that he has locked the front-door 
or that he has properly turned off the gas. The instinct of 
secretiveness probably accounts for a man opening and re- 
opening envelopes which he has addressed, in order to make 
sure that he has not put his letters in the wrong ones. These 
are examples of irrepressible fears occurring to normal indi- 
viduals. 

It is conceivable that even the above obsessions might develop 
to such an extent that mentation could be no longer regarded 
as normal. If the tunes or the rhymes became so persistent 
that the man could not attend to his business or if he spent 
all his nights going to and from the front-door or attending to 
all the gas-taps in the house, his instincts would have become 
such an annoyance to him that he would surely seek his medical 
man for relief. 

Obsessions are not the result of a Persistent emotional tone 
and are not themselves persistent; they come in attacks. The 
fears of impending harm experienced by melancholiacs are 
- not obsessions, nor are the impulses of maniacs or patients 
suffering from dementia precox. Perhaps the most important 
difference between obsessions and the fears and impulses incident 
upon other varieties of mental disorder is that in the latter 
there is no attempt to control them, whereas in the former the 
sufferer realizes the groundlessness of his dread, endeavours to 
overcome it and, at least in the case of an impulse to do some- 
thing wrong, tries to resist it. An obsessional patient fully 
realizes that there is something mentally wrong with him, but 
at the same time has the feeling that his particular obsession is 
no part of his real personality. It is as though he were influenced 
by something outside himself, but he is under no delusion about 
the matter. 

Etiology.—A history of neurosis in the patient’s family is 
obtainable in about 60 per cent. of the cases. Physical ill- 
health sometimes appears to be a determining factor. Apart 
from this the disorder is invariably traceable to some incidents 
in the patient’s past experience, which determine the nature 
of the obsession. 

Janet regards psychasthenia as a “ lowering of the psycho- 
logical tension ’’, by which he means that the psychical response 
of a psychasthenic to his environment is inadequate and less 
than the normal so that his perception of reality is deficient. 


254 MIND AND ITS DISORDERS 


Observation and examination of these patients do not corrob- 
orate this view; for not only is their perception remarkably 
keen, but it is a curious fact that they usually belong to the 
intellectual classes and not uncommonly possess exceptional 
ability. | 

Psycho-analytic investigation reveals that the essential etio- 
logical factors of this psychoneurosis are always repressed or 
forgotten situations or incidents of early infancy, the symptoms 
arising usually by “‘ transference of the affect ’’ from an im- 
portant unconscious thought to some related conscious thought 
of little significance. Freud believes that such incidents invari- 
ably have some sexual significance. My own experience confirms 
this view in the majority of the cases; but I have analyzed some 
of these patients to the extent of effecting a complete recovery 
without discovering any sexual relationship. These have all 
been cases of the morbid dread of heights, and it may be that 
some sexual import might have been disclosed if the analysis had 
been continued. 

Irrepressible Thoughts.—These commonly take the form of 
philosophical questionings arising from the instinct of inquisitive- 
ness, such as: “‘ Is there a personal God ?”’ “ If so, who created 
Him ?’’ ‘‘ Was there ever a beginning of all things ?” “If so, 
did time exist before that ?”’ These questions constantly recur 
and cause real mental unrest to the patient. Régis and Pitres 
refer to a man who suffered mental anguish from the recurring 
thought that the Kaiser or a president of a Republic had to 
smile five hundred or a thousand times at a reception. Hack 
Tuke recorded the case of a London undergraduate who was 
constantly worried by the question where the word “not” 
should be placed in a sentence containing it. These are a few 
examples; there is, of course, no end to the thoughts that may 
obsess such patients. 

Irrepressible Fears.—For the sake of convenience a general 
description of the commonest “ phobias’’ or morbid fears is 
given in this place, but it must be understood that not all phobias 
are symptoms of the obsessional neurosis. The same recurring 
fear may in one patient be hysterical and in another obsessional. 
The differential diagnosis is made during psycho-analysis, when 
it will be found that the symptom is a compromise in the first 
patient and a replacement in the second. In hysterical cases 
the sense of fear or anguish is stronger than in obsessional ones. 
Many of these irrepressible fears have received, perhaps some- 
what unnecessarily, specific names. 


PHOBIAS 255 


The fear of dirt (mysophobia) which appears in many forms 
is the commonest of all. Analysis usually reveals that dirt 
symbolizes “dirt ’’ in a moral sense. Patients suffering from 
this obsession are fairly comfortable so long as everything and 
everybody near are still; but, should anybody be moving in the 
room, they fall into a state of mental anguish lest some of the 
dust raised by the movement should fall upon them or their 
clothing. Some shake their clothing every few minutes. Others 
avoid handling it, or any other articles for that matter; and 
should such action become necessary, they wash their hands 
afterwards. Consequently they wash fifty times a day or more 
—a symbolic action also in many psychotic cases. Obsessional 
patients are quite capable of appreciating the absurdity of their 
actions and attitude of mind and they may often attempt to 
resist the impulse to wash. A struggle between impulse and 
reason ensues and they remain in that most distressing of all 
emotional states, doubt, from which there is no relief for them 
until the hands are washed. The appearance or knowledge of 
the existence of a small piece of dirt of any kind causes them 
mental anguish and is sure to lead to a fusillade of questions. 
_ At the time when gas was the illuminant at Bethlem, one patient 
required to know at lighting-up time what had become of each 
match used for lighting the gas lest by some mischance a small 
piece of the charred end might be floating about the ward and 
ultimately come in contact with herself or her clothing. Not 
content with the assurance that all the burnt matches had been 
put in the fire, she would require a detailed account of what 
would happen if they had not been put in the fire. 

In another patient the disorder was initiated by her finding 
a bug among her clothes. From that time she developed an 
abnormal dread of coming in contact with such vermin. The 
weekly change of bedding caused her much distress on account 
of the possibility that a bug might find its way from the laundry 
into her room. Such patients, if not looked after, will not 
change their clothing from one year’s end to another. 

Owing to the dissemination of medical knowledge by the lay 
press in recent years the fear of microbes is becoming rather 
common. When the microbic origin of cancer was on the tapzs 
I had a patient who feared that she might have the cancer 
microbe on her. Being of an altruistic nature, her main idea 
was to avoid contaminating others. If a plateful of food was 
placed before her, she took care to eat until the plate was clean. 
She would rather eat fish-bones, nut-shells and egg-shells than 


250 MIND AND ITS DISORDERS 


run the risk of allowing any food touched by herself to come 
into contact with others; and she suffered mental torture when 
she was prevented from eating such refuse. Subsequently, of 
course, her food was always specially prepared for her and all 
inedible parts removed beforehand. | 

The appearance of a cat causes mental anguish to some people. 
One of our greatest generals, a man who knew no fear in the 
presence of a death-dealing foe, suffered from this. 

That hallucinations may occur in this disorder is obvious 
from the fact that some of the patients see dirt, vermin etc., 
where there isnone. The following case is of interest on account 
of the development of psychomotor hallucinations in association 
with it: 

The patient was an unmarried woman, aged twenty-eight, and 
her illness dated from an occasion when some pieces of glass 
froma broken lamp fell into the bath at her home. At first she 
developed the fear that the glass might not have been all cleared 
away and that some fragments might find their way into her 
vagina. Then she feared that some insect might crawl there 
during sleep and breed; especially she feared that she herself 
might accomplish this end during sleep by unconsciously intro- 
ducing hair or other material contaminated with microbes. 
Psychomotor hallucinations then developed in which she felt 
her hand move to her head and pull out hairs, although she saw 
that her hand and arm were motionless by her side. She re- 
covered after two years’ hospital care; but has since relapsed 
and been cured by psycho-analytic treatment. 

Agoraphobia or fear of open spaces is a condition in which 
the patient suffers from a feeling of oppression, often accom- 
panied by palpitation, cold sweats and tremors whenever he 
passes into an open space such as a public square or field. 

Claustrophobia is a state in which the patient suffers from 
similar symptoms when he is in a confined space such as an 
ordinary room or a railway-carriage. Acrophobia is an abnormal 
fear of heights; nyctophobia, fear of the dark. Some people 
have a similar sense of oppression when they are in a church 
or a theatre, crossing a bridge or in a crowd. Stage fright is 
a phenomenon of like nature. The insane fear of glass has 
received the name crystallophobia. 

There are some patients who suffer from the fear that an 
organic reflex over which they have no control may occur in 
awkward circumstances. The most common form of this 
obsession is the fear of blushing (ereutophobia) on meeting 


MORBID IMPULSES 257 


strangers, the natural result of such fear being that the patient 
does blush. Another common form is coprophobia, the fear of 
evacuating the bowels when visiting other people or in a theatre 
or at church (church diarrheea), the fear producing the dreaded 
result. Stammerers and ticqueurs suffer from a constant morbid 
fear of their stammer or tic. Here again the fear that they 

should stammer or tic causes the symptom to manifest itself; 
_ but these are hysterical rather than obsessional cases. 

An insane dread of doing or having done some harmful action 
is a common form of obsession. Such patients may fear that 
they have destroyed something valuable. A clergyman was 
compelled to visit all the communicants every Sunday afternoon 
after he had administered the Sacrament, to satisfy himself that 
he had not accidentally dropped some pins into the chalice 
and thus caused them to be swallowed by communicants. The 
same patient, if he had passed an open inkpot, would get the 
notion that he might have pushed somebody into it. He realized 
the absurdity of such an idea and resisted the temptation to 
go back and look into the inkpot, but resistance was useless: 
he suffered mental torture until he had gone back and satisfied 
‘himself that there was nobody in the ink (insanity of doubt). 
This case illustrates the relationship between the irresistible fears 
and irresistible impulses mentioned below. 

Irresistible Impulses.—Here we have to deal with states of 
mind in which the patient feels impelled to perform certain 
acts against his will. Arithmomania or the impulse to count 
is one of the commonest; the patient may have to count ten 
before he answers a question; he counts his steps, the number 
of windows in each house he passes, the number of rungs on a 
ladder etc. 

There are people who are impelled to read every piece of 
printed or written matter they come across, resist how they 
will. If they go for a walk, they spend most of their time 
reading posters of all kinds. If they see any person reading a 
private letter, they are impelled to go and read it over his 
shoulder. A man living in a suburb in the North of London, 
anxious to free himself from this habit, deliberately avoided 
reading a poster in the Strand on his way home from business. 
He reached home and had his dinner; but the fact that he had 
not read the poster haunted him to such an extent that, before 
he could retire for the night, he was obliged to travel back to 
the Strand, a distance of about seven miles, in order to obtain 
relief from his mental unrest, 

17 


258 MIND AND ITS DISORDERS 


Dipsomania is another form of the disorder. Like other 
impulses it comes on in attacks during which the patient is 
unable to resist drinking alcoholic beverages to an inordinate 
extent, although he is anxious to abstain. Kleptomania is a 
recurrent impulse to steal; pyromania, a recurrent impulse to set 
things on fire, usually haystacks, heaths, commons and houses. 
Some are periodically impelled to mutilate animals, especially 
horsesand cattle. Others, again, are impelled to commit homicide | 
orsuicide. Patients of this latter class usually present themselves 
at asylums and mental hospitals as voluntary boarders asking 
to be taken care of until the impulse has passed off. 

It is curious that in the homicidal cases the patient is usually 
impelled to kill his own children. In the case of a man who has 
married a widow with children of her own whose livelihood 
depends on the patient, he has no impulse to kill these. This 
suggests that homicidal as well as suicidal impulses may be an 
effort on the part of Nature to get rid of the unfit. 

To sum up, the manifest characteristics of this form of mental 
disorder are— 

(1) Incessant recurrence of the obsession. 

(2) Resistance which almost invariably proves to be useless. 

(3) Mental anguish while the struggle between instinct and 
volition is going on. 

(4) Relief when, for better or worse, the struggle is over. 

There is no disturbance of sensation in obsessional cases and 
perception is normal except for the rare occurrence of hallucina- 
tions. The judgment is sound, there are no delusions, the 
patients have clear insight into their condition and there is no 
disturbance of memory. 

The conduct is normal between the recurrences, as also is 
emotional reaction, and there is no change of temperament. 
In other words, between the recurrences the patients are quite 
capable of managing themselves and their affairs and of attending 
to their ordinary duties. For these reasons it is not justifiable 
to regard the obsessional neurosis as an insanity, any more than 
neurasthenia or most varieties of hysteria and the anxiety 
neurosis. A large number of people suffer from obsessions of 
which they are ashamed. They kept them secret before the War 
and none of their friends suspected that they had any mental 
affliction; but conscription obliged them to declare their weak- 
ness, especially if it disqualified them from fulfilling their military 
obligations. 

Insomnia sometimes occurs and may be troublesome. 


TREATMENT 259 


Except for some exaggeration of the tendon reflexes, there are no 
physical signs known to be specially associated with the disorder. 

Prognosis.—Left to themselves these patients seldom, if ever, 
recover; and the prognosis is to be regarded as unfavourable 
if the obsessions have lasted more than a year before the patient 
comes under care. 

The prognosis is, of course, much more favourable when the 
patient undergoes psycho-analytic treatment, but some cases 
prove extraordinarily difficult. 

Pathology.—There is no morbid anatomy of the disorder. Its 
psychopathology is that the affect of a repressed complex has 
become detached and transferred to certain objects or situations 
in conscious life, which symbolize such objects or situations; the 
obsession representing a compensation or substitute for some 
unbearable idea, which has been repressed, and taking its place 
in a more tolerable form in consciousness. 

The neurosis takes its origin from a conflict, during early child- 
hood, between love and hatred towards the same person. This 
begets, on the one hand, a mental habit of uncertainty, doubt 
and weakness of will, and, on the other, an aggressive curiosity 
(especially regarding sexual matters) which leads the child into 
actions which he subsequently regrets to the extent of forgetting 
(repressing) them altogether. In the ultimate analysis, anal 
erotism and coprophilia are found to play an important role. 

An obsession is a very great distortion of the repressed idea, 
the distortion being effected, just as in dreams, by substitution, 
displacement, ellipses, inversion etc. Moreover, the primary 
‘obsession may in turn be repressed and replaced in consciousness 
by a further distortion and so on. In such patients analysis 
may be extraordinarily difficult. Other difficulties requiring 
special technique, which need not be discussed here, are also 
liable to arise in some cases. 

Treatment.—It will already have been inferred that this 
consists of psycho-analysis, which is the only cure. Repressed 
complexes are unearthed and placed in their true light. In the 
meantime there is no reason why these patients should not follow 
their usual occupation. 

Their physical health may be built up by the administration 
of a good, plain, nutritious diet, plenty of rest during the day 
and of sleep during the night. 

Constipation, anzemia and such physical disorders should be 
treated on rational lines, Maltine, cod-liver oil and the tonics 
are useful adjuncts, 


THE PSYCHOSES. 


UNDER this heading are included :— 


The maniacal-depressive psychosis; 
Paranoia; . 
Dementia preecox; 

Paraphrenia ; 

Epilepsy and its various manifestations; and 
Alcoholism and other drug habits. 


Like the neuroses and psychoneuroses, their basis is supposed 
to be purely psychical, and such morbid anatomical changes as 
have been described must be regarded as secondary; but, unlike 
neurotic and psychoneurotic patients, the psychotic usually fail 
to recognize their infirmity and therefore to adapt themselves to 
their environment, except perhapsinanasylum. The psychoses 
are the true insanities. 

From the psycho-analytic standpoint, they differ from the 
neuroses and psychoneuroses in that the infantile fixation is in 
the very earliest years of infancy. And further that the mental 
conflict is between the ego and the external world rather than 
between the ego and the unconscious id. In dementia przcox 
and in epilepsy the fixation is probably in the first few months 
of life, in paranoia and paraphrenia during the second or third 
years, in alcoholism a little later and in the maniacal-depressive 
psychosis during the third or fourth year. It will, of course, be 
understood that the fixation is affective, not intellectual; and I 
give these dates tentatively. 

The maniacal-depressive psychosis differs from the others in 
that it is not a narcissistic psychosis. In this disease the mental 
conflict is rather between the ego and the ego-ideal or super-ego. 


CHAPTER VII. 
MANIACAL-DEPRESSIVE INSANITY. 


(INTERMITTENT AND PERIODIC PSYCHOSES.) 


THE proposition that periodicity is a normal characteristic of 

mental function is so self-evident that it scarcely needs ex- 

emplification. The diurnal alternation between sleeping and 

waking, the weekly day of rest provided by the Jewish law, the 
200 


INTERMITTENT INSANITY 261 


monthly change in a woman’s character corresponding with her 
menstrual period, the annual migration of man to the seaside 
or elsewhere, which must be planned in every house of business, 
and the alternating fits of energy and laziness normal to almost 
every man and woman will at once occur to the reader. 

The insane are not exempt from this law of periodicity. Every 
form of mental disorder is liable to remission, intermission and 
alternation; but the form of insanity about to be described is 
especially characterized by remission and intermission or by 
alternation and periodicity. The subjects are lable to attacks 
of mania, melancholia or stupor, these being in some cases 
accompanied or replaced by some delusional state. 

The cases are divisible into two categories— 


(a) Intermittent insanity 
and (b) Periodic insanity. 


Intermittent Insanity, which is the commoner of the two varieties 
and, so far as the isolated attacks are concerned, the most curable 
form of mental disorder with which we have to deal, accounts 
for a large percentage of the admissions to asylums. 

The mental equilibrium of these patients is unstable. Their 
first breakdown occurs usually in the third decade and they are 
liable to repeated attacks during the rest of their lives. The 
intervals between the attacks vary in length: they may at 
first be of five, ten or twenty years’ duration; but the intervals 
tend to grow shorter as age advances, until at last the patients 
require permanent asylum care. As the attacks get closer 
together dementia supervenes, each attack leaving the patient 
more weak-minded. 

This form of insanity has been compared by the French school 
to a spinning-top. So long as the top is undisturbed it main- 
tains its vertical position; but a slight blow on the side sets it 
swaying, the oscillations being at first comparatively slow but 
becoming apparently more and more rapid as the sides approach 
the ground; finally it falls on its side and rolls away. Its spin- 
ning life is done, as is the mental life in the terminal stage of 
intermittent insanity. But it is not always necessary for the 
top to receive a blow in order to bring about its final downfall. 
Left to itself, it will ultimately oscillate and fall to the ground. 
So it is with all patients of unstable mental equilibrium; the day 
must inevitably come, if they live long enough, when they have 
a mental breakdown and become demented, no other cause being 
assignable than their inherent mental instability. 


262 MIND AND ITS DISORDERS 


The first attack may be delayed until advanced age, but the 
more unstable a patient is the earlier will be the incidence of 
insanity. 

Periodic Insanity is comparatively rare and differs from the 
above form in that the intervals between the attacks are approxi- 
mately of the same duration. The attacks themselves are ap- 
proximately of the same duration and each is an almost exact 
replica of a former one. 

This state of affairs will be readily understood on reference ~ 
to the accompanying diagram, in which red represents mania or 
some delusional condition, black represents melancholia or stupor 
and the linear spaces represent intervals of sanity. 

Periodic insanity does not tend to dementia to the same extent 
as intermittent insanity. I have seen patients with recurrent 
mania or recurrent stupor of many years’ duration, who suffered 
from as many as twelve attacks in the course of the year but did 
not show the least sign of dementia during the intervals of 
sanity. 

At any stage in the course of intermittent or periodic insanity 
it may happen that either a maniacal or melancholiac stage 
persists. In such cases the condition becomes one of chronic 
mania or chronic melancholia. 

The duration of the whole cycle in any of these states may be 
two days to two years or more, and this remains the same for 
each patient throughout the whole of life. One of my patients 
has had an attack of depression every eleven years*—viz., at the 
ages of nineteen, thirty, forty-one and fifty-two. Similarly, the 
duration of any given phase remains the same for each patient 
in each of his cycles. The various phases, however, of each cycle 
are not necessarily of equal duration as represented for con- 
venience in the diagram. 

The transition from one phase to the other may take place 
suddenly, slowly or by oscillation. In cases in which the duration 
of the different phases is short, the transition is usually abrupt 
and occurs at that important time in a man’s life, two o’clock 
in the morning, when his temperature and vitality are at their 
lowest, the time of onset of attacks of asthma and gout, the 
time when the phthisical patient feels most miserable, and the 
usual time of both birth and death. 

In other cases the attack of mania or melancholia subsides 
gradually during the course of a few days; but the patient, in- 


* Since writing the above I have had two more such cases. Medical 
psychologists will discern a possible basis for this number of years. 


RECURRENT Manla. 


RECURRENT MANIA 
(Irregular Type). 


RECURRENT MELANCHOLIA. 


RECURRENT MELANCHOLIA 


(Irregular Type). 


ALTERNATING INSANITY. 


ConTiINuous ALTERNATING INSANITY 


CIRCULAR INSANITY. 
(Two Types). 


FIG. 33.—PERIoODIC INSANITY. 


To face p. 262 


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MELANCHOLIA 263 


stead of recovering, as he apparently promises to do, becomes by 
degrees more and more depressed or excited. 

In yet other cases a melancholiac becomes excited for an hour 
or so, then sinks back into his state of depression. He becomes 
excited again, but for a greater length of time, and again he is 
depressed. This process is repeated several times, the attacks of 
excitement becoming longer and those of depression shorter, until 
at last a definite attack of acute mania is established. The con- 
verse may happen in the transition from mania to melancholia. 

Etiology.—The essential cause of the disease is mental in- 
stability, congenital or acquired. Congenital instability is 
usually the result of defective heredity, ancestors of the patient 
having suffered from mental disease, quite commonly from inter- 
mittent insanity; but, as we have already stated, there are other 
ways than heredity by which the parent may influence the child. 
The Falrets, father and son, were able to observe three separate 
families in which circular insanity occurred in the grandmother, 
mother and daughter. Mott has published similar cases. Ac- 
quired instability may be the result of alcoholism,* acute disease 
or inanition. Exciting causes are mental and physical shock, 
traumatism, gestation and parturition. 

The root complex of this psychosis:is repressed sado-masochism, 
a kind of self-punishment; but this will be considered more fully 
under the. head of pathology. 


MELANCHOLIA. 


Melancholia is a phase of intermittent or periodic insanity, 
characterized by a condition of misery in excess of that which is 
justified by the circumstances in which the individual suffering 
from it is placed, and by lack of energy owing to temporary 
weakness of the muscles controlling the movements of the large 
proximal joints. Kraepelin and his followers confine the use 
of the word “ melancholia ’’ to cases of senile depression; but 
such a limitation of the word is considered by the physicians of this 
country to be unwarranted for reasons to be considered presently. 

The several varieties may be classified according to (1) what 
the patient does and (2) what he thinks. 


if 176 
Stuporose melancholia. Simple melancholia. 
Agitated melancholia. Hypochondriacal melancholia. 
Resistive melancholia. Delusional melancholia. 


* In these cases the question arises whether the insanity and the alco- 
holism are parallel indications of the same complex—repressed homo- 
sexuality for example. 


264 MIND AND ITS DISORDERS 


Stuporose melancholia is characterized by defect or absence of 
voluntary movement, agitated melancholia by excess of certain 
movements, and resistive melancholia by active resistance to 
attention and care by others. 

Simple melancholia is characterized by the absence of delusions, 
hypochondriacal melancholia by the existence of delusions con- 


cerning the patient’s bodily organs and delusional melancholia _ 


by the existence of delusions concerning other matters. These 
several varieties will be more fully considered after dealing with — 
the symptomatology of melancholia in general. 

Melancholia has its physical signs as well as its mental symp- 
toms. The latter can be regarded as being dependent on the 
former and are therefore considered first; but it must never be 
forgotten that this psychosis is essentially psychical in origin. 

Physical Signs.—The general health of the melancholiac is 
bad. There is usually a history of loss of weight. His com- 
plexion is rather muddy on account of an abnormal dryness of 
the skin; the secretion of sweat and sebum are diminished, so 
that the latter is apt to collect in little dry masses on the surface, 
especially about the face. The hair is unnaturally dry and in 
severe cases “‘ stands on end ’’, refusing to lie down in obedience 
to the comb. The nails are brittle and inclined to spht. It has 
been ascertained that the toxicity of the sweat is diminished or, 
at any rate, not increased. 

The patient is paler than when in health, partly on account 
of a slight chlorosis, the red cells being a little diminished in 
number and the hemoglobin more than proportionately dimin- 
ished in amount. The specific gravity and the isotonic (osmotic) 
power of the blood are lessened, especially in agitated melan- 
choha. 

The temperature is slightly subnormal and rather irregular. 
The respiration is normal in frequency but shallow, while the 
pulse is somewhat increased in frequency (80 to 100) and usually 
feels weak to the finger. 

Disturbance of the digestive tract is invariable. The tongue 
is dry and coated with a white or brown fur and the patients 
frequently complain of abdominal uneasiness. The latter is 
largely an abdominal sensation of nervous origin, but there is 
no doubt that it is partly due to indigestion. The gastric mucous 
membrane, like the lingual, is dry and furred to such an extent 
that in severe cases washings from the stomach are tinged brown. 
The patient has no appetite; he loathes the very sight of food, 
which may even cause pain or vomiting. Examination of a 


PHYSICAL SIGNS OF MELANCHOLIA 265 


“test breakfast ’’ shows increase of hydrochloric acid and de- 
ficiency of pepsin in the gastric juice. The toxicity of the 
gastric juice is greater than normal. Melancholiacs are invari- 
ably constipated, partly from weakness (vide infra) of the ab- 
dominal muscles and partly on account of deficiency of the 
intestinal juices. Primarily it is probably due to repressed anal 
erotism which is an important factor of the sado-masochistic 
complex responsible for melancholia. Except when diarrhcea is 
present, itself due to constipation, the feces are dry and hard 
so that it occasionally becomes necessary for them to be digitally 
removed from the rectum. Examination of the abdomen reveals 
no physical signs of disease. 

The quantity of urine passed by a melancholiac during the 
twenty-four hours is diminished and its specific gravity is in- 
creased before treatment; but the reverse is the case when he 
is taking large quantities of milk and other fluids. There is 
an increase of the earthy phosphates in the urine and a decrease 
of the alkaline phosphates, of the sulphonates, of the total 
quantity of nitrogen and presumably of urea since there is an 
increase of urates and uric acid. The toxicity of the urine is 
increased, especially in those patients who suffer much from 
indigestion. This toxicity is possibly due to indoxyl, which is 
often excessive in the urine of melancholiacs. 

Contrary to the popular idea of melancholia there is as a rule 
no abnormal secretion of tears; that secretion is diminished with 
all the others. And when melancholia occurs as a sequel to 
parturition the secretion of milk is diminished or arrested. 

The generative function is disturbed in both sexes. Male 
melancholiacs are usually impotent, probably because the 
pleasurable tone of feeling associated with the sexual act is out 
of harmony with their general feeling of misery. In females 
amenorrhcea occurs during the acute stage of the disorder and 
disappears as the patient recovers or passes into a condition of 
chronicity. It is interesting to note the large proportion of cases 
in which this amenorrhcea lasts nine months (the usual duration 
of pregnancy)—probably a wish fulfilment. 

The most important physical signs, however, which this dis- 
order presents are referable to the nervous system. True head- 
ache is not very common but patients frequently complain of a 
sense of pressure on the top of the head (symbolizing repression). 

It is rare for convulsions to be associated with melancholia, 
and in those cases in which they occur they are infrequent. 

Most striking and important among the physical signs of this 


266 MIND AND ITS DISORDERS - 


disorder of the nervous system are the motor disturbances. The 
attitude and general appearance of the melancholiac are quite 
characteristic. Sitting, walking and lying are uncomfortable 
for him: he therefore stands. The head and trunk are inclined 
forwards as in paralysis agitans and there is slight flexion of the 
hips and knees. There is also slight flexion of the shoulders; 
and the elbows, which are rigidly held to the side, are flexed to 
a right angle. In cases of agitated melancholia the fingers are 
in constant movement during waking hours, fumbling with the 
buttons or picking holes in the skin of the fingers or face, picking 
the nails or plucking the beard. 

The facial expression is that of misery; the corners of the 
mouth are turned down and the forehead wrinkled. The wrinkles 
may be either transverse from contraction of the frontales or 


Fic. 34.—-MELANCHOLIAC WRINKLING. 


vertical at the root of the nose from contraction of the corru- 
gatores superciliorum. These transverse and vertical wrinkles 
may occur together in the same patient so as to give an appear- 
ance which has been compared by French authors, not very 
appropriately, to the Greek letter w. 

The attitude and appearance above described are dependent 
on rigidity, which is most easily observed and investigated in 
severe cases of stuporose melancholia. The rigidity affects the 
large proximal joints most and the small peripheral joints least; 
for this reason I have called it “ proximal rigidity ’’ in contra- 
distinction to “‘ peripheral rigidity ’’ such as occurs in ordinary 
hemiplegia. The voluntary muscles of the trunk (especially 
back and neck) are most affected, those of the shoulders and 
hips to a less degree and those of the elbows and knees least. 
The wrists, fingers, ankles and toes are usually free from rigidity. 

Coextensive with rigidity, as in many other nervous diseases, 


PHYSICAL SIGNS OF MELANCHOLIA 267 


there exists slight paralysis (weakness) of the affected muscles. 
Melancholiacs can rarely hold their arms vertically above their 
heads and when they shake hands they do so from the wrist. 
They walk slowly and from the knees rather than from the hips. 


Fic. 35.—MELANCHOLIAC HANDSHAKE (LEFT). 


The patients themselves state that they have “ difficulty in 
doing things ”’. 

The condition is one of slight double-hemiplegia: the bilaterally 
acting muscles are therefore affected. Although ordinary reflex 


Fic. 36.—MELANCHOLIACS SHAKING HANDS. 


(medullary) respiration is unaffected, voluntary respiration of 
cortical origin (taking a deep breath) is shallower than natural, 
a symptom which sometimes causes the patient to believe that 
he has “no breath’’; and here we should not lose sight of the 
symbolic valuation of breath-—familiar to psycho-analysts. 


268 MIND AND ITS DISORDERS 


Melancholiacs have difficulty in showing their upper teeth; they 
have to open the mouth widely in order to do so (I am here 
referring to severe cases). 

I have observed two ocular symptoms of this paralysis: one 
is nystagmoid jerking on extreme lateral deviation of the eyes 
and the other is weakness of accommodation. I have prepared 
some very small test-types by photographing the ordinary test- 
types for reading. Shortly after admission I make a note of — 
the largest of these types which the patient is unable to read 
and I find that, on recovery, he is able to read it easily, and 
often a type two or three sizes smaller. Melancholiacs some- 
times complain that near objects look larger than natural; this 
naturally reminds us of the similar symptom in true internal 
ophthalmoplegia. 

I have suggested that the sensitiveness of the melancholiac 
to noise is due to weakness of the tensores tympanorum, but this 
must form a subject of future investigation. 

Phonation is weak, lower pitched than in health and mono- 
tonous. Similarly articulation is weak, the patient appearing 
to his friends to be taking less trouble than usual in the pro- 
nunciation of words. 

In the less severe forms of melancholia speech is deficient and» 
in melancholiac stupor absent. Even in mild cases of simple 
melancholia it is an effort for the patient to join in a conversation 
and still more so to originate one. Melancholiacs are slow in 
reacting to questions, slow, as in all their actions, in answering 
them, and their answers are as brief as they can conveniently 
be made. There is no true aphasia, motor or sensory. 

Writing, which is but another mode of speech, is similarly 
affected. It is a trouble to melancholiacs; hence, in the acute 
stage at least, it is slow and the calligraphy is so altered that 
it resembles that of a child. All this is nothing more than a 
special manifestation of the slight universal paralysis above 
referred to. 

The superficial reflexes (scapular, epigastric, abdominal, plantar 
etc.) are all, as in hemiplegia, less marked than in health. The 
plantar reflex is associated with a flexor response to the great toe. 

During the acute stage the tendon reflexes are all diminished— 
a feature which helps to differentiate this psychosis from anxiety 
hysteria. The knee-jerks are equal and characterized by quick- 
ness of reaction, both in the forward and backward movement, 
especially in the latter. As a result of this the actual excursion 
of the foot is small. If, in testing the knee-jerk in the acute 


Be hth all their ae Reel ; pei 
till loved laces. riban ugles, 
Br one Opie Syn is tay ee hel 


retained ‘a passion 
for her paduasoy, 
because I formerly 


Fa Nt Cmte 


happened to say 
it became her: 


Be tlm hon, 


. 
and by ali 
wetont, and be weve 
‘ we put 
tnt 
wetny come a ale 
‘tay “yw my 
4 tree Ne 
wumptaary cdicts could 
* not restrain How well wo 
fever TD fancied my lectures: 


against pride had con 
quered the vanity of my 
Wiughtors yet J still found 


them sceretly attached & 


FIG. 37..—FACSIMILE OF TEST-TYPES USED IN THE INVESTIGATION 
OF MELANCHOLIA, BY WHICH IT MAY BE DETERMINED THAT 
MELANCHOLIACS SUFFER FROM WEAKNESS—2.e., PARTIAL 
PARALYSIS—OF ACCOMMODATION. 


To face p. 268 


MENTAL SYMPTOMS OF MELANCHOLIA 269 


stage of melancholia, a finger be placed behind the knee the 
semimembranosus tendon will be felt to spring into prominence 
in apparent simultaneity with the tap on the patellar tendon. 
Clonus never occurs. . 

The electrical reactions of the muscles are normal. 

Mental Symptoms.—Sensation is normal in a typical case of 
melancholia. Peripheral analgesia may appear as a complica- 
tion in a few cases. When it occurs, it is to be regarded as an 
exhaustion symptom. 

Perception is normal and the patient is able to understand 
the nature of his environment. He cognizes objects and recog- 
nizes people correctly. Except for lack of attention, to be 
presently described, the appreciation of time and space is good. 
The power of reviving a percept, of calling up a memory image, 
in short, of ideation, is usually deficient and sometimes abolished. 
For example, a woman suffering from severe melancholia is often 
unable to picture the faces or to recall the voices of her children. 
This would also appear to be due to the paralysis of attention, 
since a greater amount of effort is necessary for ideation than 
for perception. Hallucinations do not occur in uncomplicated 
_acute melancholia, but some cases of chronic melancholia may 
be complicated by hallucinations of hearing, the basis of such a 
complication being presumably the explanation of the chronicity. 

The psychical characteristics of melancholia can all be ex- 
plained on the hypothesis that they depend upon the physical, 
especially the motor, symptoms. The combination of an attitude 
of general flexion and adduction, shallow respiration, constipa- 
tion and:high blood-pressure gives rise to a feeling of depression 
(vide the chapter on Emotion). 

There is paralysis of volitional, instinctive and emotional 
reaction. Accordingly the patient complains that his will-power 
is gone, that he is unable to occupy himself as in the past. He 
cannot bring his volitional attention to bear upon matters which 
concern him, even when they are of the utmost importance. Such 
is the paralysis of volition that even automatic acts, everyday 
habits of life, may cease. 

Similarly there is paralysis of emotional reaction. The 
musculature has fixed the patient in an attitude of misery and 
nothing will alter it. You may tell him the most excellent joke, 
but he does not laugh; you may tell him that his favourite 
daughter is dead, but he does not weep. He says that he cannot 
feel such things now. This Joss of feeling, of which melancholiacs 
complain, must not be confused with loss of sensatton—the 


270 MIND AND ITS DISORDERS 


difference needs only to be pointed out to the student to prevent 
him from falling into this error. 

In like manner instinct is paralyzed. The melancholiac has 
no desire for outdoor games, for sociak or sexual intercourse, 
or even for food. Not only is there paralysis of the instinct to 
eat, but the patient also suffers from indigestion, due to his 
constipation and apepsia. Under such circumstances it is no 
matter for surprise that food is revolting to the patient and that — 
he frequently refuses it altogether. He has no self-confidence, 
his instincts of emulation and rivalry are gone. If he is a 
collector of any sort of thing, he loses interest in his collection 
and now suggests that he has wasted his life over it. He is 
neither constructive nor destructive. In severe forms of melan- 
choliac stupor the instincts of locomotion and of cleanliness are 
gone; the patient stands immobile and may even be wet and 


Name: Miss C. F., zt. 30 years. Disease: Melancholia, 
March, April. May. 


Zoe Poe faa eff ede ered pe flat ee Ufo ele 


caer taceeevaraes COREE ECE 
i \aaae aN ae NC PEE 


ANCA 
INIT TI 
| 


Hours or Steep 


SC oN OU Pe Wh 


p+ 
aaaeaes 
i 

ans 

Sy 

BP est bp | he] 

a22caum 

mei 

ere 

ited 


dirty, but this is uncommon. Instinctive attention is paralyzed 
and apparently, in a few cases, even reflex attention, so that the 
patient cannot be startled. 

The memory of melancholiacs is quite good except in so far 
as they lack interest in and pay no attention to events going on 
around them. 

They have difficulty in getting to sleep; they awake unrefreshed 
and their depression is accordingly worse in the early morning. 
During the acute stage of their disease they have bad dreams. 
Happy dreams are one of the earliest symptoms of recovery. 

All melancholiacs are potential suicides, but some are so 
suicidal that they are constantly on the watch for an oppor- 
tunity to do themselves bodily harm; their life is devoted to 
courting death and they require the closest supervision. Some 
authors go so far as to classify such patients separately as cases 


MENTAL SYMPTOMS OF MELANCHOLIA 271 


of “‘ suicidal melancholia ’’, but this is not to be recommended 
lest it should divert attention from the fact that all melancholiacs 
are liable to commit suicide. 

Most melancholiacs have good insight into their condition; 
but if once they lose sight of the truth that all this enormous 
wealth of symptoms is due to an illness, those very symptoms at 
once become the premises for erroneous judgments; not that 
they reason consciously about their symptoms, but that their 
symptoms give them the feeling that such and such is the case 
and, for no other reason than that they have this feeling, they 
judge and believe it to be so. There is of course some sort of 
subconscious reasoning about the matter. 

They feel that their will-power, their emotions, their instincts, 
their attention and their ordinary habits of life, all symbolic of 
a living spirit within, have ceased. In other words, they feel 
and therefore judge and believe that their soul is lost. Hence 
arise the delusions that they are deserted by God, eternally 
damned, have committed the unpardonable sin, are everything 
that is vile and worthless, unfit to live and already suffering the 
tortures of hell. 

If they are animists, they think they are dead, non-existent or 
“a little spot of black away in the distance ’’. A few patients 
interpret the symptoms more materially and believe their brain 
to be gone, a delusion which is fostered by a peculiar sensation 
of numbness about the head. 

Hypochondriacal melancholiacs, who are impressed by the 
physical rather than the psychical manifestations of their disease, 
complain of the weakness and sometimes of the stiffness. Some 
say that they are paralyzed, a judgment which scarcely deserves 
to be called a delusion; others go so far as to say that their legs 
are made of glass or some such brittle substance and they behave 
accordingly. 

If it is the abdominal discomfort, due to indigestion and con- 
stipation, which has most impressed the patient, he believes 
that his bowels are obstructed, that they are on fire, that he is 
about to suffer torture from peritonitis, that his throat is blocked, 
that the food goes into his head, that his abdomen is distended 
with food and that there is no more room inside, that he is filled 
up with cancer, and so forth in endless variety. 

The amenorrhcea of the female melancholiac gives rise occa- 
sionally to the delusion that she is pregnant (the fulfilment of an 
unconscious desire), and she accuses herself falsely of adultery 
with some man towards whom she may in the past have con- 


272 MIND AND ITS DISORDERS 


sciously entertained tender feelings (again the fulfilment of an 
unconscious wish). 

Senile melancholiacs are liable to develop delusions of financial 
ruin and to accuse themselves falsely of having led a reckless 
life, of having failed to save money for their old age or of having 
ruined their firm by falsifying the books. It is useless to show 
them the books in order to demonstrate that all is well; nothing 
will change their delusion. ) 

All the above patients attribute their condition to something 
amiss with themselves; but there is another class of melanchohacs, 


Fic. 39.—AGITATED MELANCHOLIA, 


much smaller than the last, who ascribe their condition to inter- 
ference by other people. These interpret their inability to do 
things as due, not to their own weakness, but to an increased 
resistance in their environment. They feel that they could 
occupy themselves as they did formerly, were it not that their 
occupation had been made more difficult for them. In this way 
they develop delusions of persecution, they believe that other 
people are against them, even that there are worldwide con- 


VARIETIES OF MELANCHOLIA 4z3 


spiracies to do them harm. This is one of the conditions which 
used to be called ‘‘ acute paranoia’, a confusing term which has 
fortunately been allowed to drop. 

Clinical Varieties.—States of melancholia vary in degree, from 
little more than a “ fit of the blues”’ to a condition in which 
nearly all the symptoms above enumerated may easily be 
detected; but apart from this there are several well-marked 
clinical varieties. 

Stuporose melancholia (melancholiac stupor, melancholia at- 
tonita) is a condition in which the paralysis is so complete that 


Fic. 40.—MELANCHOLIAC GAIT. 


the patient neither moves nor speaks. Left to himself, he stands 
silent and motionless in the same position, rigidly fixed in the 
characteristic melancholiac attitude already described. Slight 
cases of melancholia are usually mild examples of this class. 
Agitated melancholia is a variety in which the patient, while 
preserving the characteristic melancholiac attitude, is in con- 
stant movement; this movement takes place, very naturally, 
in just those parts which are least paralyzed, viz., the fingers 
18 


274 MIND AND ITS DISORDERS 


and wrists, knees, ankles and, when not restrained by boots, 
the toes. He paces about, walking, not from the hips, but 
from the ankles and knees, wringing his hands, picking pieces 
of skin from his fingers or face, or fumbling with the buttons of 
his coat. These movements are usually accompanied by such 
exclamations as ‘‘Oh dear! How dreadful! What a wicked 
wretch I have been!’ and so forth. Craig believes the blood- 
pressure is lower than normal in these cases. 

Resistive melancholia is a variety in which resistance to the 
usual attention and care is the most striking feature. It is a 
rare condition. Most of the cases formerly classed under this 
heading are now recognized to be katatoniacs. 

Hypochondriacal melancholia, which may appear in the guise 
of any of the above forms, deserves special recognition because 
of its relatively intractable nature and also because of the special 
proclivity of its subjects to suicide, generally with the idea of 
calling attention to their case. 

Melancholia may be said to have become chronic when most 
of the physical signs of the acute stage have passed off, while 
the patient remains in a persistent state of mental depression. 

In some cases of delusional melancholia the physical and 
mental attitude of misery pass away, but the patients are left 
with a disordered judgment and retain their delusions. Such 
cases might be designated “ melancholiac secondary delusional 
insanity ’’. On the Continent it is called “‘ melancholiac secon- 
dary paranoia ’’; but it is better to reserve the term “ paranoia ”’ 
for the condition hereinafter described as such. 

Senile Melancholia.—With advancing age a man’s general 
temperament tends to be more and more serious and tinged 
with a constant feeling of depression as, little by little, he sees 
all possibility of attaining the aspirations of his youth vanishing 
away. When a man retires from business, his days of labour 
being over, he sees that there is no more money coming in, has 
visions of a penniless old age and hence becomes depressed. 
Senile melancholia is possibly nothing more than an exaggeration 
of this normal depression of old age; but my own impression 
is that this would be correctly classed as a depressive stage of 
maniacal-depressive insanity. 

Kraepelin used to regard it as a separate disease of the in- 
volution period and claimed apprehensiveness and restlessness 
as its peculiarities, while he considered psychomotor retardation 
and impediment of volition to be characteristic of maniacal- 
depressive insanity. Moreover, the prognosis for intermittent 


SENILE MELANCHOLIA 275 


and periodic melancholia is good, while amelioration is not to be 
expected in senile melancholia. 

Now certain of these premises are erroneous, for apprehensive- 
ness and restlessness undoubtedly occur in maniacal-depressive 
melancholia, and psychomotor retardation and impediment of 
volition undoubtedly occur in senile melancholia. Furthermore, 
when maniacal-depressive melancholia recurs in senility or pre- 
senility it tends to become chronic. Another point to be con- 
sidered is that involutional melancholia is related by heredity to 
maniacal-depressive insanity; for I have seen many instances 
in which a parent has senile melancholia while the offspring 
suffer from the maniacal-depressive psychosis. 

Nevertheless, I am quite open to conviction in this matter, and 
Farrar has so far accepted involutional melancholia as an entity 
that he distinguishes three varieties: 


Melancholia vera, with delusions of past wickedness and 
consequent perdition of his soul; 

Anxtetas presenilis, with delusions of immediately impend- 
ing harm, verbigeration, rhythmical movements and sug- 
gestibility ; and 

Depressio apathetica, with mild depression and loss of interest. 


Prognosis.—Leaving, therefore, the senile cases out of con- 
sideration; unless the case has been improperly treated in its 
early stages and has passed into a condition of chronicity before 
being placed under skilled care, melancholia should always be 
regarded favourably. The signs of chronicity are disappearance 
of the physical signs without corresponding mental improvement. 
If the digestion has become normal and the obstinate constipa- 
tion has disappeared, if the urine is normal and the menstruation 
regular, and if the patient looks physically in good health and 
has become fat without corresponding mental improvement, the 
case may be regarded as chronic. Other signs of chronicity are 
the development. of hallucinations of hearing and, in women, 
the growth of bristly hair on the face; but perhaps these are 
indications that the diagnosis has been erroneous. 

In the majority of cases, chronicity is reached or recovery 
achieved within six months of the onset of the disease. 

In a few cases the general nutrition of the patient is disturbed 
to such a degree that death occurs as the direct result of the 
melancholia. 

There is no tendency to dementia in melancholia. Even 
chronic melancholia need not always be regarded as hopeless. 


276 MIND AND ITS DISORDERS 


The author had one case of recovery (female) after eighteen years’ 
duration, and has had under his care one patient (male) who 
had recovered from a previous attack of thirty-five years and 
another (male) who had recovered from a previous attack of 
seven years. One severe case of senile melancholia recovered 
attemthrecwears, | 

Treatment.—Improvement of the general nutrition is the key- 
note of the treatment of melancholia. In order to attain this 
result the patient must have— 


1. Complete mental and physical rest. 
2. A good, plain, liberal diet. 
3. Careful supervision to prevent self-injury. 


He must be put to bed and well fed. 

The treatment of melancholia by rest in bed requires to be 
insisted upon. By some misconception of the nature of the 
disease a regrettably common notion has got abroad that the 
melancholiac requires to be “‘roused’”’ out of his condition. 
Before the War neurologists used to recommend “ travel’’, now 
they prescribe “ distraction ’’; the result is the same in both 
cases, for the patient is sent sightseeing. 

And if he is sent to an institution for the insane I believe 
I am understating the facts when I say that, in nine cases out 
of ten, the chief endeavour of both doctors and attendants is to 
make the patient occupy himself in some way or other: “ occupa- 
tion ’’’ is the watchword in most asylums. 

Now I say nothing against occupation for chronic patients in 
good physical health; but to set a patient suffering from any 
acute disease to work, merely because that disease has psychical 
manifestations, is, I venture to assert, irrational. Even if it 
be granted that occupation is good for the mind, it is obviously 
wrong to disregard the enormous array of physical symptoms 
detailed above. 

Rest in bed is recognized as correct treatment for functional 
or organic disease of any other organ than the brain. I have, 
indeed, heard of a lay person recommending a patient suffering, 
for example, from acute rheumatism, to “‘ walk it off’’, but not 
of a physician recommending such treatment; but as soon as 
the mind becomes disordered, the whole of the fundamental 
principles of medical treatment are set aside and the patient is 
worried to distraction. 

Nature does what she can in the matter and suggests the 
correct treatment by paralyzing the patient; and, if physicians 


TREATMENT OF MELANCHOLIA 277 


would adopt her suggestion, they would not only be doing a duty 
to themselves by obtaining more satisfactory results, but they 
would be also doing a duty to the community by reducing the 
number of chronically insane. 

This bed-treatment is no novelty. Griesinger recommended 
it as long ago as 1865 and I am justified in my earnest advocacy 
by its being now almost universally adopted in France, Hol- 
land, Switzerland and Russia. I have observed the results 
of both methods and it is my experience which causes me to 
urge rest so strongly. Indeed we need scarcely any further 
consideration than that the patient’s illness begins while he is at 
his usual occupation, which he has selected as that for which he 
is best adapted. In view of this fact, why on earth should 
occupation, especially an untried occupation, be regarded as 
treatment ? The answer is only too obvious. 

Bed-treatment must not be shirked merely because there are 
difficulties in the way. Surely the chief interest of our pro- 
fession lies in the facing and overcoming of difficulties. 

The first difficulty is that the patient objects to bed; but 
every physician of experience knows that the melancholiac 
objects to any form of treatment. A competent attendant soon 
overcomes the objection by taking away the patient’s clothes at 
the first opportunity. Some patients, by way of excuse, say that 
bed makes them worse; but they alter their opinion in course of 
time if the physician remains firm. 

The second difficulty is that the patient either sits up in bed 
and refuses to lie down, or he does not remain in bed at all but 
stands by the bedside. Here again a tactful attendant can do 
a great deal and his work may be lightened by the use of sedative 
drugs. To young patients a couple of drachms of paraldehyde, 
night and morning, give not only the desire for rest, but also a 
certain amount of much-needed rest. In older patients half a 
drachm or less of the liquor morphine bimeconatis three times 
a day works like a charm. Tincture of hyoscyamus may also 
be used with advantage in some of these restless cases. 

The imsomnia must be combated by placing the patient in 
circumstances conducive to sleep. The room must be quiet and 
warm, but not stuffy; there should be sufficient bedclothes, but 
not too many. When these measures are insufficient, a glass 
of hot milk at bedtime often serves as a useful hypnotic. Fre- 
quently, however, it becomes necessary to resort to the use of 
drugs. j 

There is a great multitude of hypnotics to select from, but 


278 MIND AND ITS DISORDERS 


they must not be used indiscriminately; the nature of the in- 
somnia should be first ascertained. 

When the patient is fairly somnolent, but liable to wake at 
frequent intervals during the night, a good sedative at bedtime is: 


Sodium bromide .. ae ae sf Af o's th aes 
Tincture of hyoscyamus a a os libs 
Water a ae ae ais "8 ~ ere ele 


When the patient has difficulty in getting off to sleep, but re- 
mains asleep if once started, the following is a good prescription: 


Paraldehyde ‘ie oe Je - rau oye 
Aq. menth. pip. .. wie 7 oe ad 3j. 


If a more prolonged effect is required than can be obtained 
by means of paraldehyde, amyiene hydrate, in doses of I to 14 
drachms in an ounce of water, is strongly to be recommended. 
At the moment of writing it is difficult to obtain this drug, but 
two or three tablets of dial are a good substitute. 

Sulphonal is not to be recommended for melancholiacs. It is 
liable to accumulate in poisonous doses in the intestines on 
account of the extreme constipation and to cause hematopor- 
phyrinuria. Such a result is to be deplored, for many of the 
patients suffering from this complication die within three weeks; 
moreover, I have seldom seen a patient recover from mental 
disease who has suffered from hematoporphyrinuria. Sulphonal 
is a drug which is known to produce degeneration of the neuron, 
and. it is in all probability this action which accounts for the 
incurability of patients who have been poisoned with it. 

The same remarks apply to trional. This drug is less liable 
to cause hematoporphyrinuria, but more liable to cause neural 
degeneration; so much that Soukhanoff, in his experiments on 
degeneration of the neuron in animals, found that trional pro- 
duced this effect more readily than any other drug. 

Nevertheless I have seen good results from the use of both 
sulphonal and trional in senile melancholiacs, who are less liable 
to hematoporphyrinuria than younger patients. It may also 
be remarked that males are less liable to this condition than 
females. 

As soon as the urine becomes tinged with red on account of 
the presence of hematoporphyrin, the correct treatment is to 
get rid of the accumulation of sulphonal or trional in the intes- 
tines by obtaining a free action of the bowels and to administer 
copious doses of lime-water, 5 ounces with an equal quantity of 
milk every four hours. 


HYPNOTICS IN MELANCHOLIA 279 


The author’s experience of veronal, a drug which has been 
much vaunted of recent years, has not been satisfactory. If the 
insomnia is absolute and a sufficient dose of veronal be given to 
procure sleep, it also induces vomiting on the following morning. 
The drug is useful in milder cases. Medinal (sodium-veronal) 
appears to be a better hypnotic and does not cause vomiting. 

Enough has been said of physical rest; now with regard to 
mental rest. The notion of giving the patient something to 
occupy his mind is still much too prevalent. Patients are 
given games to play, cards, draughts and even chess in order 
to occupy the mind; or they are given odd jobs to do, with the 
same object, and incidentally to relieve the attendants. 

Now I hope that no words of mine will serve to increase un- 
necessarily the already too heavy labours of attendants on the 
insane. But the attendants can hardly be said to be relieved 
when the result of this treatment is a prolongation of the acute 
stage of the patient’s illness or the conversion of an ordinary 
melancholiac into a heavy nursing case. It may be argued that 
occupation gives the patient something else to think about. 
Verily it does give him “ something else ’’ in the sense of “‘ some- 
thing more’’ to think about; but his mind is concentrated on 
his own wretched condition as well as his occupation. As to 
the games, can anything be more incongruous than to allow a 
patient who requires mental rest to play chess ? Chess at least 
should be contraband of acute insanity. 

By all means let the convalescent and chronic patients assist 
the attendants or play games; but let not patients in the acute 
stage of mental disorder be treated by worrying the very organ 
which is affected, lest it lead to permanent mental disablement. 

It is sometimes argued that the patient must think of some- 
thing, and it is best that he should not think of his own mental 
troubles. I cannot agree with this view. The amelioration of 
the insane is already far advanced if they have been induced to 
believe that their state is one of illness and that the illness is 
curable; and nothing will impress these facts upon them more 
than to make them lie in bed and do nothing, just like any 
ordinary hospital patient, and to see that the doctors and atten- 
dants are doing their very best to procure their recovery. 

Nourishment.—One of the most important instruments in the 
armamentarium of any institution for the cure of melancholia is 
a weighing-machine; and the feeding of the patients must be 
so adjusted that the machine shows, week by week, a steady 
increase in their body-weight. This fundamental principle in 


280 MIND AND ITS DISORDERS 


the treatment of mental disorder has been called the “ gospel of 
fatness’. Patients must be fed on a good, plain, nutritious diet, 
without excess of nitrogenous constituents. 

If a patient fails to increase in weight, extra food should be 
insisted on. The form which this extra diet takes must be left 
to the discretion of the physician. The writer is in the habit 
of recommending three extra pints of milk, with or without the 
addition of cream. Other useful adjuncts are a mash of bananas 
and cream after dinner, a cup of hot cocoa at bedtime, and 
chocolates. 

Cod-liver oil may be strongly recommended, not the nasty, 
oily, indigestible, yellow product, but the old-fashioned brown 
fishy oil, from which the jecorin and other digestive constituents 
have not been removed by refining processes. 

Care must be taken not to carry this overfeeding to excess 
lest it defeat its own object by upsetting the patient’s digestion, 
making him sick and rendering food even more objectionable to 
him than it was before. 

Food may be made a little more pleasant by giving the patient 
an appetizer a quarter of an hour before meals, such as: 


Dilute nitrohydrochloric acid “ oe Perera |i 
Tincture of nux vomica .. ote ee oe “Tie 
Syrup of orange (or the tincture with gluside) .. 3j. 

Compound infusion of gentian.. ov to 3}. 


A glass of port with dinner serves as a useful digestant. 

It is also to be remembered that these patients suffer from 
apepsia, they may therefore be allowed a small dose of liquor 
pepticus immediately after meals. Soured milk given for a fort- 
night at a time proves an excellent corrective for the digestive 
troubles, and it improves the patient’s general nutrition at the 
same time. It acts best when given with a vegetarian diet. 
Alcohol and drugs must be avoided while the patient is under- 
going a course of this treatment. 

For various reasons melancholiacs at times refuse to take 
sufficient nourishment to increase their body-weight. This may 
occur even among convalescents, who become anxious about their 
previously slim figures. With the latter class those in attendance 
upon the patient should tactfully fail to observe any notable 
increase in the patient’s rotundity. 

All too frequently, however, refusal of food is a persistent 
symptom, which can be combated by forced feeding only. As 
soon as the patient ceases to put on weight, there must be no 
quarter; it becomes the duty of the attendants to force with a 


TREATMENT OF MELANCHOLIA 281 


spoon the last portions of each meal upon him; and if the resist- 
ance is so active that such measures fail, it is necessary for the 
patient to be tube-fed. 

Massage and gentle faradism are also to be recommended as 
further aids to nutrition. The massage, which is most advan- 
tageously carried out between ten and twelve in the morning, 
should be general or at least employed for the neck and shoulders, 
spine, hips, thighs and abdomen. The faradism, which should 
be stimulating but not too unpleasant, should be applied to the 
same areas with the exception of the abdomen. 

The constipation of melancholia is often very troublesome to 
treat. For the treatment of this symptom the reader must refer 
to works on general medicine; but he should remember that 
melancholiacs, and the insane generally, require stronger purga- 
tives and larger doses of them, than constipated members of the 
sane population. It is frequently necessary to resort to copious 
enemata of soap-and-water. The writer often employs the fol- 
lowing compound enema for his patients, who find it both 
effectual and comforting: 


Olive oil be ee ar ss “. vary A) Sa 
Castor oil .. sie Ye oe ste 2. ij. 
Glycerine a ae yt ate a, AI. 
uEpentine .. ae oe tt ae Fe | ag: 


Digital evacuation of the rectum is occasionally necessary. I 
have had excellent results from hormonal, a drug introduced for 
constipation some years before the War, but at present unobtain- 
able, so far as I am aware. The injection of a single dose 
into the gluteal muscles cures constipation for at least some 
months. 

When the patient’s nutrition begins to show signs of consider- 
able improvement he may be allowed to get up, at first for a 
few hours in the evening, bed-treatment being then gradually 
reduced. 

During this period of convalescence he may begin open-air 
exercise in the form of drives or short walks; and, while he is 
indoors, occupation, games and entertainments all make for 
recovery. Should he show any signs of relapse, he must be 
sent back to bed for further treatment. 

Prevention of Suicide and Self-Injury.—Patients must be 
deprived of all means of doing themselves bodily harm. Poison 
and firearms are, of course, absolute contraband of lunacy. 
Knives and scissors should be under lock and key and the atten- 


282 MIND AND ITS DISORDERS 


dant in charge of such articles should know exactly how many 
there are. On each occasion when they have been used they 
should be re-counted in order to ascertain that none are missing 
before locking them away again. Similarly medicines should 
always be under lock and key. 

The rooms in which the nursing is carried out should be free 
from projections liable to serve as possible conveniences for the 
patient to hang himself. Gas-flames and fires in the room should 
be protected by strong wire guards. The patient should not be 
allowed a handkerchief at night lest he strangle himself with 
it under the bedclothes; nor is it permissible for him to wear 
sleeping garments made of any substance which may be torn 
noiselessly, e.g., flannelette, lest he use a strip for purposes of 
strangulation. 

Melancholiacs, at least those who are actively suicidal, should 
be under constant observation and have no opportunity of 
secluding themselves. It should be impossible for them to 
obtain possession of any keys, and there should be no bolt to 
the door of the w.c. 

Constant supervision is the best safeguard for suicidal patients; 
but, even under the most careful observation, they contrive at 
times to do themselves injury. A chance cup of boiling tea 
suffices to produce a fatal cedema of the glottis, a secreted hairpin 
may serve the purpose of a dagger or a sudden dive from the 
height of an ordinary chair may fracture the base of the skull. 
It speaks volumes for the attendants on the insane that suicides 
are not more frequent in asylums. 

Occasionally it happens that the physical signs, so far as 
our crude methods of examination are able to detect, pass away 
and the patient gets fat and apparently well in physical health, 
without corresponding improvement in his mental condition. 
This is especially hable to happen to patients who have just 
passed through an attack of acute mania. Physical health has 
been restored apparently to perfection, but the mental improve- 
ment “‘ o’erleaps itself and falls on the other ’’’, and they become 
depressed. If, after a further course of treatment on the lines 
above recommended, the patient remains persistently depressed, 
what is to be done ? 

It has been observed that some such patients make a rapid 
recovery after an attack of acute physical illness, e.g., erysipelas. 
Accordingly it has been recommended that an acute physical 
illness should be induced and the illness which has been selected 
for the purpose is hyperthyroidism. The patient is put to bed 


HYPERTHYROIDISM FOR MELANCHOLIA 283 


and treated for a week with thyroid gland, conveniently in the 
form of tabloids. During the course of the 


First day, he takes 30 grains of gland—6 5-grain tabloids 


Second ,, a 40mm inf Seyi} nf 
Abird a Ciar y 7, LO Sade, rs 
Fourth ,, ss GOaves iP Daas » 
Batth 7. Af GG) arp es bie to FA ys 
Sixth Ai yy 40 oo ” 8 5- ” ” 
Seventh _ AO tags; ” Oates ” 


at suitable intervals. His temperature should be taken regularly 
and the pulse carefully watched. Slight rises of temperature 
are unimportant, but irregularities of the pulse should be treated 
with digitalis and strychnine. Patients with a small thyroid 
must be treated with smaller doses of the gland. The patient 
loses 5 to 10 pounds during the treatment, sometimes improves 
mentally, but more often deteriorates. Towards the end of 
the week he begins to look physically ill. The ordinary treat- 
ment of melancholia is now started de novo and in quite a satis- 
factory proportion of cases the end justifies the means. The 
patient passes through a short stage of convalescence and finally 
recovers. 


MANIA. 


Mania is that phase of intermittent or periodic insanity which 
is characterized by a condition of excitement or exhilaration in 
excess of that which is justified by the circumstances in which 
the individual suffering from it is placed and by disproportion- 
ately excessive activity of the movements of the large proximal 
joints. 

Four varieties have to be considered, viz.: 


Simple mania. 

Acute mania. 

Acute delirious mania. 
Chronic mania. 


Mania, like melancholia, has both physical signs and psychical 
symptoms, the latter being possible of explanation on the hypo- 
thesis that they are dependent on the former. The physical 
signs of the several varieties of mania differ in degree only, but 
they are most characteristic in acute mania. 

Physical Signs.—Although the maniac persists, as a rule, in 
maintaining that he is in excellent physical health and feels 
well, strong and virile, his general health is in reality far from 
good. 


284 MIND AND ITS DISORDERS 


There is usually a history of loss of weight; he looks ill and 
pale and is perhaps anemic. The tongue is furred, the appetite 
poor and the bowels constipated; but these signs are not so 
marked as in melancholia, for the maniac at times eats vora- 
ciously and the bowels may act regularly. 

There is an increase in the quantity and amylolytic power of 
the saliva and an increase of hydrochloric acid in the gastric 
juice, which has been found to be more toxic than normal. 

The pulse is frequent, but not as a rule disproportionately 
frequent in relation to the patient’s motor activity. There is 


Fic. 41.—ACUTE MANIA. 


slight chlorosis and the toxicity of the blood is increased. The 
temperature 1s normal, except in acute delirious mania. 

There is increase of nearly all the secretions. The sweat is 
abundant and is said to possess a ““ mousy ’’ odour. In puerperal 
cases the secretion of milk is increased and liable to cause trouble 
by tending to the formation of mammary abscesses. 

The quantity of urine is increased and there is an augmenta- 
tion of the total quantity of solids which it contains. Injected 
into animals the urine of maniacs is said to cause local spasms, 
hypothermia and mydriasis. 

In women menstruation is irregular in time and in quantity, 
but it is rarely suppressed as in melancholta. 


PHYSICAL SIGNS OF MANIA 285 


Signs of disorder of the nervous system are, however, most 
important of all. General hyperesthesia, which will be subse- 
quently considered, is the rule. 

There are no paralytic symptoms and no rigidity. On the 
other hand, the most characteristic feature of acute mania is 
great motor excitement. A rather coarse tremor of the hands 
and face occurs in some Cases. 

Observations on movements of the insane in general, and of 
maniacs in particular, are best made on female patients in the 


Fic. 42.—ACUTE MANIA. 


garden; because females react more readily than males to ordinary 
stimuli, and movement is less restrained in the open air. 

The movements of a maniac in a state of motor excitement 
take place for the most part in the large proximal joints. The 
trunk sways freely as the patient walks, and when he runs, there 
is exaggerated movement at the hips. In the waving of the arms 
which is common in mania, the greatest movement takes place 
at the shoulders and there is little movement of the hands and 
fingers. The maniacal handshake is from the shoulder and the 


286 MIND AND ITS DISORDERS 


maniacal attitude of prayer is with hands upraised to heaven; 
whereas the melancholiac attitude of prayer is with hands 
clasped in front of the sternum. The typical attitude of the 
maniac is with the elbows abducted from the side, while that 


Fic. 43.—MANIACAL HANDSHAKE. 


(Drawn from a photograph.) 


of the melancholiac is with the elbows close to the side. It is 
interesting to correlate this observation with the results obtained 
from normal people with the automatograph (p. 55). 

The superficial reflexes (scapular, gluteal, cremasteric and 
plantar) are exaggerated. Stroking the sole of the foot elicits 


MENTAL SYMPTOMS OF MANIA 257, 


a flexor response of the great toe. The tendon reflexes, e.g., 
knee-jerks, are usually diminished during an attack of motor 
excitement but may be exaggerated during a period of rest. 

Mental Symptoms.—In the course of an attack of acute mania 
two stages have to be recognized: the stadium acutum and the 
stadium debilitatis. The mental characteristics of. these must be 
separately considered. 

In the stadium acutum there appears to be augmentation of 
all modes of sensation. Patients in this condition are sometimes 
able to hear every word of an ordinary conversation fifty yards 


Fic. 44.—MANIACAL HANDSHAKE. 


away, provided they are undisturbed by other sounds; and I 
have known a patient call my attention to the ringing of church 
bells which could only just be heard by myself, and were quite 
inaudible to a neighbouring attendant. Similarly, if the point 
of a pin be lightly applied to the patient’s skin, he starts or 
screams. Faint odours also are easily detected by acute maniacs. 
These symptoms are of importance in the differential diagnosis 
of mania from other states of excitement. 

Perception is normal and often extraordinarily keen, and the 
medical officer usually hears a few home truths from these 


288 MIND AND ITS DISORDERS 


patients on his morning round. Hallucinations and illusions do 
not occur, except as a rare complication of the malady. 

The maniac has deficient control of his emotions; he laughs, 
cries or grows angry for little or no reason. Similarly he has 
deficient control of his instincts; he is erotic, in some cases to 
such an extent that modesty is lost, but this is unusual. He 
collects rubbish systematically, hoards up old newspapers and 
stores away useless odds and ends with fantastic tidiness. He is 
at once constructive and destructive; he tears up an old garment 
with the intention of converting it into a new one, but the 
renovation never takes place. 

The instinct of self-adornment is exaggerated; simple maniacs 
adorn themselves with flowers, brilliantly coloured ties and 
perhaps grotesque hats; mild cases of acute mania decorate 
themselves with leaves and wear pieces of string on their fingers. 
Other patients, more severely afflicted, may perhaps tear the 
coloured borders off their blankets and swathe themselves 
fantastically to represent gypsies or Zulus. The instinct for 
mischief and practical joking is augmented. Ornaments are put 
on the fire, the gas is blown out and the room turned topsy-turvy 
for fun. The instinct of noisiness is exaggerated; the patients 
scream, shout and sing. Their uncontrolled activity gives them 
an illusive sense of well-being and they may hence become 
boastful and exalted about their capabilities. 

Some such patients feel ready to defy death; a dangerous 
symptom, since it may lead them to commit suicide by accident. 


‘‘ There with fantastic garlands did she come 
Of crow flowers, nettles, daisies, and long purples, 
That liberal shepherds give a grosser name, 
But our cold maids do ‘ dead men’s fingers’ call them; 
There, on the pendent boughs her coronet weeds 
Clambering to hang, an envious sliver broke; 
When down her weedy trophies, and herself, 
Fell in the weeping brook. Her clothes spread wide; 
And mermaid like, awhile they bore her up: 
Which time, she chanted snatches of old tunes, 
As one incapable of her own distress, 
Or like a creature native and indu’d 
Unto that element: but long it could not be, 
Till that her garments, heavy with their drink, 
Pulled the poor wretch from her melodious lay 
To muddy death.”’ 


Maniacal patients are incapable of sustained volitional atten- 
tion; but instinctive attention is easily aroused, any chance 
percept serving to divert the current of their thoughts. In 


CONDUCT IN MANIA 289 


this way arises one form of incoherence. If, for example, a 
maniac be talking of his state of health, the rattle of keys will 
at once turn his conversation to the subject of keys, and so forth. 
Similarly, a word may suggest others rhyming with it; a hat laid 
on the bed may set him talking in this wise: “‘ That hat, cat, rat, 
bat” etc., the chance sound claiming instinctive attention. 

Association of ideas is very active with these patients, their 
ideation flowing more rapidly than normally, and more rapidly 
than words can be uttered to express them (“ flight of ideas ’’). 
This symptom gives rise to another form of incoherence, in 
which connecting-links in the train of thought are elided. In 
the following example, quoted from a police-report, it is possible 
to supply the links in some places, but not in others. Probably 
it is not a case of mania, but it is a good example of incoherence: 
‘“ IT have got millions of money and am going to Windsor. I went 
to heaven yesterday and it was very dark. My mother and 
dead relations welcomed me and I went out with them. The 
Lord said to me: ‘ You are the Holy Ghost; the Trinity is now 
complete’. I was born every evening and came here on the 
third. They said I was mad, but I was not. All the money I 
got I gave to the Lord and had not a penny left. I was with 
some of the finest men, you know. I shall have France, and 
Russia as well, and there will be one God from north to south. 
We call this the Green Island and the Green Moon, and England 
will be called the Rose Moon. There will be ever so many more 
moons, and that is the explanation of all these little stars. I want 
a few millions, and I will make a millon—ten millions—to-day. 
But I cannot move without the consent of the Queen to marry 
me. Every man will have as many wives as he likes. The Lord 
told me the reason, and there will be no more doctors. I shall 
have a thousand of the most beautiful women, and if a man takes 
a fancy to any of them he will have to pay me what I like, and 
all the money will go to the benefit of our glorious Empire. 
You should have seen how pleased my mother was. Every 
morning at half-past five all the little children were examined 
by God. I can read a man’s character well. I can read yours. 
You are a very honourable gentleman; I know almost every 
incident in your life. I’m just going to Windsor now. Will 
you gentlemen have a silver moon luncheon with me? Charlie, 
old fellow, here is £5,000 for you. George, I will make a Cabinet 
Minister of you. I have been honourable to my foster-sister.”’ 

The memory of maniacal patients is good. 

The insomnia of mania differs somewhat from that of melan- 

Tg 


290 MIND AND ITS DISORDERS 


cholia in two particulars. In the case of a melancholiac the 
number of hours of sleep during each night remains fairly con- 
stant; in the case of a maniac the number of hours is extremely 
variable as shown in the accompanying chart. Further, what 
little sleep there may be in mania occurs during the earlier 
hours of the night; in melancholia it occurs during the later hours. 

Most maniacal patients have good insight into their condition; 
but if they lose that insight delusions at once arise, usually as a 
result of the feeling of power given by abnormal stimulation of 
the cerebral cortex. 

Maniacs have a feeling of increased will-power and hence 
believe, in some instances, that they can influence the will of 
others. Such patients will stare at others in the belief that they 


6 


are ‘‘ willing ’’ them to perform certain acts. They will tell the 


Name: Miss A. A. R., zt. 24. Disease: Acute Mania, 
March. April. 


stot te fe eee allel sale lsieiele be [eal ie fief] efer 
a atlas BREEN PES 


i i He 


uA | Hi 


ys 
~ 


Hours or Steep 


} 
2 
5 
4 
5 
6 
Ch i 
8 
9 


doctor that they are curing other patients by will-power. Some 
believe themselves to be lords, dukes, kings, God Almighty or 
possessed of untold wealth. 

The speech of acute maniacs is commonly incoherent for reasons 
already considered. Articulation is normal. 

The writing is also incoherent; the calligraphy untidy, irregular 
and besmirched with blots. The first line may be written at the 
bottom of the page, the paper is then turned upside down or 
sideways and another line written and so on until the page is 
nothing but a tangled mass of words. 

The second stage of acute mania is one of exhaustion, “ calm 
after the storm’”’, the so-called stadium debilitatis. After the 
stage of excitement has subsided the arms fall to the side and the 
patient sinks into a condition of stupor. He has analgesia of 
the arms, forearms and hands, as well as of the legs from the 
ankles to the knees; in some cases the analgesia is more, in others 


STADIUM DEBILITATIS 291 


less extensive. He knows all that is going on around him, but 
takes no apparent notice. 

Hallucinations of hearing may arise in this condition. 

The flow of thought is slow, in contradistinction to the “ flight 
of ideas’’ of the acute stage. If undisturbed the patient sits 
silently in the same position all day long. There is neither 
rigidity, flaccidity nor flexibilitas cerea. If the patient’s arm 
be raised by the doctor to some unusual position, he quietly 
returns it to the comfortable posture from which it was removed. 
He is unemotional and his more lately acquired instincts are in 
abeyance. The memory is fairly good. 

In a few cases this post-maniacal condition of stupor becomes 
exaggerated and persistent, and it assumes the characteristics 
of anergic stupor to be presently described. Usually, however, 
in the course of a few weeks the stupor gradually passes off 
and the patient enters the stage of convalescence. The skin 
becomes clear and the flesh firm, the body-weight increases, the 
appetite returns and all the organs begin to function normally. 
Complete recovery usually takes place within a few months; 
but it must not be forgotten that in some patients a state of 
melancholia supervenes. 

Simple mania is a milder condition, similar to that which occurs 
to a slight degree in most normal individuals about the seven- 
teenth year, when a boy begins to feel that he is a man and that 
the world lies at his feet. He goes to the University feeling con- 
fident that he will be able to take all the degrees it offers, and any 
remonstrance on the part of his parents is regarded as nonsensical 
interference. When this feeling gets out of hand the boy becomes 
a simple maniac. He buys a revolver in order to retaliate against 
any parental interference, becomes engaged to many girls, drinks 
whisky and shaves his hairless face so as to be a man. One 
patient sawed off the corner of the drawing-room table because it 
was in his way. The simple maniac pays unusual attention to 
his dress, which is extravagant; he wears flowers in his button- 
hole and uses scent. He is garrulous, boastful, argumentative 
and at times brilliant in repartee. His memory is quite accurate. 
His emotions are excessive, he is either exuberantly jovial or 
extremely irritable. The deeper meaning of many of the above 
symptoms will be obvious to the medical psychologist. 

Although the above condition happens most characteristically 
during the period of adolescence, it may occur at any time of life. 
The author has seen one case at the age of fifty-two, and many 
during the fifth decade. 


292 MIND AND ITS DISORDERS 


Acute delirious mania is a phase of intermittent insanity in 
which all the characteristics of acute mania are excessive and 
there are, furthermore, physical signs of an acute febrile disturb- 
ance. The temperature is raised, commonly to 101° F., some- 
times to 103° I’.; sordes appears on the lips, teeth and tongue, | 
which latter is coated with a thick brown fur; the pulse-rate is 
perhaps 140 to 150 and the respiration 30 to 35. Complete in- | 
somnia and absolute constipation are the rule. The patient 
refuses food and is frequently unable to retain any nourishment 
or medicine, even administered by means of the feeding-tube. 

Chronic mania presents the same symptoms as acute mania; 
but it differs in that the condition does not pass away, the patient 
remaining permanently in a state somewhat resembling the 
stadium acutum above described. Further, the symptoms are 
less marked than in acute mania. In chronic mania we some- 
times meet a remarkable exaltation of memory (hypermnesia). 
One patient, who was in Bethlem for some years, could always 
remember the name of any medical man who had visited the 
wards, perhaps years previously, although the institution was 
then visited by a large number of medical men every year. 

Chronic maniacs are lable to acute exacerbations from time to 
time, each of which leaves the patient more weak-minded. The 
memory gradually fails. The above patient, indeed, reached a 
stage in which he failed to recognize former Bethlem house- 
physicians whom he had at one time seen daily for six months. 

Prognosis.—The outlook in all cases of acute and simple mania 
is, as a rule, favourable for the existing attack. A few cases of 
acute mania die of exhaustion from the disease or from some 
intercurrent complication, and a still smaller number become 
transformed into a condition of chronic mania. The duration of 
most cases of acute and simple mania is from five to seven months, 
but it may be as short as a fortnight or as long as two years. 
If the patient has had a previous attack, the physician will, as 
a general rule, do well to be guided in his prognosis by the dura- 
tion and character of that attack. 

The prognosis of chronic mania is bad in respect of recovery 
but good in regard to life. The author has, however, seen a few 
cases of chronic mania recover, one after about five years. 

It has been said that about 50 per cent. of cases of acute 
delirious mania die of exhaustion from the disease and that a 
considerable proportion of the remainder become permanently 
weak-minded. This is certainly not the experience of the author, 
who regards these cases more favourably. A considerable 


CHRONIC MANIA 293 


number have already entered upon convalescence within a month 
if they have been energetically treated. About 25 per cent. die 
of exhaustion, and the author is now of opinion that some of 
these might possibly be saved. He has seen but one case that 
became permanently weak-minded. 

Treatment.—Many years ago when I approached the study 
of mental disease it was a great surprise and somewhat of a 
shock to me to find that wan and emaciated patients in a state 
of acute excitement were allowed to spend their days dancing 
round the gardens of institutions for the insane, save when 
their motor excitement proved too much for the other patients, 
when they were allowed to perform their wild gyrations within 
the confines of a padded room. On inquiry I was told that it 
was better to let them “ have it out ’’, so I subscribed to existing 
doctrines and many a time satisfied my desire to do some real 
good in the world by disturbing a quiescent maniac and setting 
him to take a run round the garden. 

Truly it was difficult to discover the rationale of such treat- 
ment; but conscience could always be salved by the shibboleth 
“Vis medicatrix nature ’’; but now, after years of experience 
and repeated observation of the results of Continental methods, 
I am constrained to dissent from the traditions of this country 
and to advocate as the essential principle of treatment of acute 
maniacal states what our forefathers would have stigmatized and 
some of the present members of our branch of the medical pro- 
fession still stigmatize as a heresy—rest ! rest in bed ! 

I admit that it is no easy matter to get an acute maniac to rest 
in bed; but the difficulty is not insuperable. In many cases a 
tactful attendant is all that is required: his duty is to induce the 
patient to remain in bed, not to hold him there, for it is no rest 
to be held down. 

If other measures fail, a course of prolonged baths should be 
tried. The use of such baths has been in vogue since the days 
of Pinel and many have been the modes of application. The 
outcome of experience is that the following is the best: 

The temperature of the bath should be 96° to 98° F. On the 
first day the patient remains in the bath for half an hour; on 
the second day, one hour; third day, two hours; fourth day, 
three hours, and so on up to six or seven hours a day. It is 
not known how the bath acts, but its effect is that the patient 
gradually becomes more and more restful. He enjoys the bath; 
he may at first be somewhat restless and turn somersaults in 
it. Should this activity become at all excessive, he can soon 


294 MIND AND ITS DISORDERS 


be dissuaded froin it by a sympathetic attendant, who should 
never leave the bath-room. In time the soothing effect of the 
warmth or the pressure of water, whatever it may be, begins to 
tell and the patient sinks into a state of quietude. After the 
bath he should return to bed and be persuaded to remain there | 
as much as possible. Females undergoing the treatment should | 
wear a gown of some sort or a chemise. A course of iron tonic 
should be given at the same time, inasmuch as this bath treat- 
ment is rather liable to cause chlorosis. 

When it is decided that the course has done its work, the 
duration of the bath should be gradually diminished.  Bed- 
treatment should then be substituted, perhaps with the addition 
at first of a daily bath of one hour’s duration. 

As soon as quietude is restored the patient may sit up half an 
hour twice a day for a smoke; but he should not be allowed to 
play exciting or exhausting games. As he improves, this half- 
hour may be gradually prolonged and he may be allowed to 
perform light duties about the room or ward. 

Meanwhile the patient must have abundant nourishment. He 
should take in addition to his ordinary food 3 pints of milk, at 
times with cream, and he should have a plentiful supply of 
biscuits while undergoing the bath treatment. A glass of stout 
or port with dinner and supper may serve as an appetizer and as 
nourishment; but alcohol must, of course, be withheld if it has 
played a role in the causation of the disorder. 

If, as in some cases, there should be absolute refusal of nourish- 
ment, the patient must be tube-fed. Tube-feeding lasts rarely 
more than a few days in the case of a maniacal patient. If 
undigested food from the last meal should be returned up the 
tube, this should be taken as an indication for subsequent meals 
to be peptonized. 

The only drugs which are indicated in the treatment of acute 
maniacal states uncomplicated by intercurrent disease are motor 
sedatives and hypnotics. Sulphonal serves the purpose of both 
and may be regarded as almost a specific for acute mania. The 
dose, which should be administered every night as long as the 
insomnia is severe, is 30 grains for a man, 20 grains for a woman. 

Sulphonal rarely acts on the first night, but after about three 
doses its effect begins to be noticeable; there is more sleep during 
the night and less motor activity during the day. Isopral is a 
milder drug of the same nature, which often acts beneficially; 
the dose is 30 to 40 grains for these patients. It should be 
administered in a spoonful of jam. 


TREATMENT OF MANIA 295 


Dial and amylene hydrate are satisfactory hypnotics in these 
cases, and hydrobromate of hyoscine, 79 grain three times a day 
by the mouth, frequently serves as a useful motor sedative. 

The action of the bowels should be regulated on ordinary 
medicinal principles. 

Acute delirious mania is a condition which demands special 
consideration because it is liable to resist all the ordinary methods 
of treatment. The patient gets no sleep in spite of drachm 
doses of sulphonal; he refuses all nourishment and if he is forcibly 
fed with even a small quantity of liquid food his stomach rejects 
it; he is constipated, no aperient can be administered and it is 
impossible for the attendants to give him an enema. What is 
to be done ? 

Chloroform is our sheet-anchor in this condition. The patient 
is anesthetized and the rectum cleared, either digitally or by 
means of anenema. His temperature is taken, he is washed with 
warm water and soap and changed into comfortable clothing. 
While he is deeply under the anesthetic a tube is passed into the 
stomach, which is then washed out with a dilute solution of 
carbonate of soda, followed by warm water. A feed is then 
administered consisting of I pint of milk, 2 ounces of cream, 
2 ounces of white mixture and 40 grains of sulphonal. The 
patient is made comfortable in bed and the anesthetic continued 
carefully for another hour. He is not aroused from the anes- 
thetic, but is carefully watched until his sleep is apparently 
natural. He is then left in quietude. The sleep continues for 
many hours; he wakes up refreshed and makes a fairly rapid 
recovery. Although the author’s experience of this method of 
treatment is limited to a small number of cases, the beneficial 
results have been so striking that he has no hesitation in recom- 
mending the method as a routine treatment for obstinate cases 
of acute delirious mania. In each of the cases the patient’s life 
was undoubtedly saved by the adoption of this method. 

Chromic mania calls for no special treatment except during 
an acute exacerbation, which should be treated like an ordinary 
case of acute mania. In a county asylum much unskilled, or 
even skilled, labour can be obtained from these patients. 


ANERGIC STUPOR. 


Anergic stupor is a phase of intermittent insanity in which the 
patient is neither excited nor depressed, but apathetic, lethargic 
and torpid. The condition is rare. It may be primary in its 


296 MIND AND ITS DISORDERS 


origin; more frequently it develops from melancholiac stupor of 
from post-maniacal stupor. 

Physical Signs.—The patients are, as a rule, in poor physical 
health and ill-nourished. Except for an occasional excess of . 
secretion of sweat about the face, there appears to be little dis- 


turbance of the cutaneous secretions; but the complexion is, as _ 


a rule, sallow. The temperature is in many cases subnormal. 
The pulse is slightly increased in frequency and of low tension; 
the respiration normal in frequency but shallow. The ex- 
tremities are nearly always cold and, at least in cold weather, 
blue, swollen and cedematous. In some cases in which there is 
marked cedema of the hands and feet, some cedema may also be 
observed in the face, especially about the nose and lips. 

There is little evidence of disturbed digestion, but the patients 
are invariably constipated. The urine is deficient in quantity, 
high-coloured and contains excess of indoxyl. In _ females 
amenorrhecea is the rule. 

The patients do not suffer from headache, pain or subjective 
sensations of any kind and there are no local paralyses. There 
is well-marked peripheral analgesia. 

There is no rigidity or flexibilitas cerea; the limbs are flaccid. 
If the arm be raised and allowed to fall, it “ flops ’’ down to 
the patient’s side. Similarly if the leg be raised, it falls to 
the ground lke a log. In severe examples flaccidity of the 
trunk may sometimes be observed. The patient lies in bed in 
any position in which he is placed, for all the world like a rag 
doll. There is muscular hypotonia or atonia as shown in Fig. 46: 
this patient, if placed in the attitude there represented, would 
remain in it for hours together. There is no laxity of the lga- 
ments; it is impossible, for example, to hyperextend the fingers, 
as in many cases of amentia, 

The superficial reflexes are diminished, the plantar reflex being 
accompanied by a flexor response of the great toe. The tendon 
reflexes are increased. A tap on the patellar tendon elicits a 
knee-jerk of large excursion, rapidly followed by a brisk con- 
traction of the semimembranosus. 

There is almost complete absence of movement, the patient 
remaining in any position in which he is placed. Similarly 
speech is absent; at most, the patient replies in monosyllables. 
The electrical reactions of the muscles are normal. 

Mental Symptoms.—In view of the extensive analgesia and, 
perhaps, anzesthesia which occur in most of these cases it is not 
surprising to find that consciousness is at a low ebb. Of idea- 


ANERGIC STUPOR 207 


tion there seems to be none; and, in some cases at least, the same 
may be said for perception, for Clouston quoted the case of a 
female patient who took no notice of another patient committing 
_ suicide by hanging herself before her very eyes. We may there- 
fore accept the statement of stuporose patients after recovery 
-that they do not experience hallucinations or illusions during 
the course of their illness. 

If there is no perception there can be no emotion, for emotion 
is essentially a reaction to a percept; nor can there be any in- 
stinct; in the majority of these cases instinctive movement is 
absent as well as volitional. The instinct to eat is lost. If a 
plate of food be placed before the patient he takes no notice of 


Fic. 46.—HYPOTONIA IN ANERGIC STUPOR. 


it and, if left to himself, would starve. He has to be fed and 
dressed by the attendants. Nevertheless, in mild cases of anergic 
stupor the patients will dress themselves, and females may do 
their own hair. Some will also take the trouble to visit the 
water-closet when necessary, but the majority are wet and dirty. 

Again, if there be no perception, there can be no memory. 
Accordingly we find that most of these stuporose patients on 
Tecovery have no memory of the major part of their illness; it 
is blank. 

It is difficult to ascertain how much they sleep. hey he 
quietly in bed the whole night through and it would be most 
unwise to disturb them in any way for the purpose of deter- 
mining whether they are asleep, lest this should arouse them 


298 MIND AND ITS DISORDERS 


from slumber. It is also difficult to decide how much their 
stuporose condition serves the purposes of sleep and how much 
true sleep they really require. 

Delusions do not arise during the course of anergic stupor; 
but a few patients subsequently develop delusions as to the 


nature of their illness. For example, one patient thought that - | 


she must have been hypnotized by some person or persons un- 
known. . 

Anergic stupor lasts from three months to three years ac- 
cording to the severity of the case. Although treatment may 
modify the course of the disease, many cases last from two to 
three years in spite of the most generous and energetic methods. 

When the stupor is about to pass off, the patient’s instincts 
return gradually to their normal condition. He begins to eat of 
his own accord, becomes clean in his habits and takes some 
interest in his personal appearance and surroundings. He moves 
about, holds conversation with others and the mental condition 
becomes clear. As a rule, there is a slight reaction after the 
prolonged period of quiescence and the patient has an attack of 
mild excitement lasting a few weeks. 

Prognosis.—The prognosis in cases of anergic stupor is good, 
and the recovery, as a rule, complete. A few cases terminate 
in a short, sharp attack of acute mania or melancholia. It is 
regrettable that a small number of patients who are unfortunate 
enough to get into the hands of persons, even medical men, 
unskilled in the treatment of such cases, die of inanition. 

Treatment.—It must be at once understood that it is useless to 
attempt to “‘rouse”’ these patients. It would be as reasonable 
to treat a case of toxic amblyopia by sending him to view the 
pictures in the Academy as to treat a case of anergic stupor by 
sending him holiday-making in the country or globe-trotting. 
The proper treatment of anergic stupor is rest in bed and a 
generous diet. The “ gospel of fatness’ applies to this as to all 
forms of insanity. Tube-feeding is rarely required, but it is 
almost always necessary for the attendants to administer every 
meal for months together by means of a spoon or feeding-cup. 
The minimum daily diet should be 4 pints of milk, 4 eggs, and 
4 ounces of cream. This may be varied occasionally with bread 
soaked in some nourishing soup (not a meat extract), or milk 
puddings. 

If it can be definitely ascertained that the patient gets in- 
sufficient sleep, a couple of drachms of paraldehyde nightly can 
do no harm and will probably do much good. 


TERMINAL DEMENTIA 299 


General massage for an hour daily helps to increase nutrition 
and, when the patient has put on a considerable amount of 
flesh, an attempt may be made to restore sensibility to the 
anesthetic limbs by the daily use of an electrical wire-brush 
and cold baths. 

When he has acquired a good covering of fat, he may be 
allowed to get up regularly at midday. He should not be 
allowed to rise earlier until there are definite signs of the illness 
drawing to a close. 


TERMINAL DEMENTIA. 


As already stated, periodic insanity tends but little to dementia. 
Intermittent insanity, on the other hand, tends to dementia to 
such an extent that it may be taken as a fairly constant rule that 


Fic. 47.—ANALGESIA IN A CASE OF TERMINAL DEMENTIA 
OF MANIACAL-DEPRESSIVE INSANITY. 


the sixth attack leaves the patient so weak-minded that he is 
no longer capable of managing himself or his affairs, and for 
ever afterwards requires permanent care, usually in an asylum. 
Each attack leaves him more weak-minded, the condition sub- 
sisting between the earlier attacks being known as “ partial 
dementia ”’ 

In partial dementia the most recently acquired mental func- 
tions show signs of degeneration. Some deficiency of reasoning 
power is manifest in the patient’s conversation; the formerly 
ardent patriot may become, for example, a rank pacifist. Volun- 


300 MIND AND ITS DISORDERS 


tary attention cannot be sustained so well as formerly; duties 
are neglected and the man’s attention is more likely to be domi- 
nated by his instincts. In some cases this latter characteristic 
may land the patient in gaol, for the legal mind is mostly in- 
capable of recognizing partial dementia. There is deficient 
control of the emotions and outbursts of anger are common. 
The memory shows signs of failure, especially inability to recall 
proper names and to remember recent events. 

In the terminal stage, after some dozen attacks or more, the 
mind is completely lost. There is peripheral anesthesia, more 
or less excessive. The man is incapable of recognizing his friends 
or of apprehending the nature of his surroundings. He has no 
idea of time and his memory becomes a blank. His instincts 
and desires are gone; he has no idea of feeding himself and 
consequently he has to be spoon-fed. He is periodically wet 
and dirty and therefore, unless carefully tended, liable to bed- 
sores. His attention cannot be aroused; he can understand 
nothing that is said to him and there is no attempt at speech; 
lastly, he may be bedridden and incapable of any but reflex 
movement. 

All physical signs of the acute stages of the disease have, as a 
rule, disappeared by the time the patients reach this terminal 
condition. Their muddy complexion may give them a generally 
unhealthy appearance, but they are not especially liable to con- 
tract disease, except perhaps phthisis. Asa rule, therefore, they 
live to old age. On the other hand, their power of overcoming 
and surviving any intercurrent disease is smal] and their general 
vitality is so low that the most trivial malady is likely to lead to 
a fatal termination. 


PATHOLOGY OF MANIACAL-DEPRESSIVE INSANITY. 


Post-mortem examinations and the microscope have failed 
alike to throw any light on the nature of these diseases. In some 
cases of long standing the weight of the brain is slightly less 
than normal and there is some excess of cerebro-spinal fluid. 
On microscopical examination it is found that there is slight 
chromatolysis of the largest cells of the cortex, but scarcely more 
than may be found in the brains of patients dying from some 
thoracic or abdominal disease in a general hospital. 

Accordingly many theories have been advanced as to the 
essential nature of maniacal-depressive insanity, most of which 
take little or no cognizance of the brain being the organ at fault. 


PATHOLOGY OF MANIACAL-DEPRESSIVE INSANITY 301 


Some writers have claimed that indigestion is the cause of the 
disease, others fix on constipation; others again blame the 
kidneys and Craig attributes the disease to alterations in the 
blood-pressure. 

In those materialistic days the present writer used to give 
reasons for supposing that there is an intraneuronic intoxication, 
but all such hypotheses have now been laid to their well-deserved 
rest and the tracing of hereditary factors never added one iota 
to our real knowledge of the malady. 

Although all sorts of physical manifestations have been 
described, no physical basis for the disease has ever been demon- 
strated in spite of the most careful macroscopical, microscopical 
and chemical investigations, and we have to face the fact that the 
maniacal-depressive psychosis is a pure psychosis. 

The psycho-analysis of several of these patients by Professor 
Freud and his disciples has thrown a flood of light on the true 
nature of the malady. Although it is frequently possible to 
discern some psycho-analytical interpretation of the symptoms 
during the course of an attack of mania or melancholia, a thorough 
psycho-analysis of the patient can only be undertaken during the 
intervals between the attacks. 

It would appear that the melancholia is the original or radical 
phase of the psychosis, which is erected on a basis of repressed 
sado-masochism. During the infantile hfe of the patient there 
has been somebody of biological importance (usually some near 
relation such as father or mother) whom he ought to have loved 
and perhaps did love consciously, although reasons occurred for 
an unconscious hatred of this same person. Consequently there 
is an unconscious desire to punish this person; but another curious 

‘complication then arises in that the patient unconsciously identi- 
fies himself with this object of unconscious hatred (introjection), 
the result being that the reproaches are directed against his own 
ego by his super-ego or ego-ideal. Hence arises the sado-maso- 
chistic state of self-punishment with its self-reproaches, delusions 
of unworthiness and wickedness and the still less disguised 
manifestation—suicide. 

Mania, on the other hand, is to be regarded as a sort of sym- 
bolized triumph of the patient on the occasion of his acquiring 
freedom from the object which has caused his suffering. In some 
patients the excitement takes the form, not of triumph, but of 
anger. Of course he does not know why he triumphs or why 
he is angry; he does not even know who or what is the object 
of his triumph or anger. 


302 MIND AND ITS DISORDERS 


During the course of the psycho-analysis other complexes, 
varying from patient to patient, become revealed. Repressed 
homosexuality, for example, is by no means uncommon. 


REMARKS ON THE GENERAL MANAGEMENT OF INTERMITTENT 
AND PERIODIC INSANITIES. 


We have seen that the characteristic of these insanities is a 
tendency to recurrent attacks of mental disorder, each attack 
resembling the last in character and duration, and the problem 
arises whether it is possible to avert them without psycho- 
analysis. To a certain extent it is. The patient should lead 
a regular life, have plenty of sleep and nourishment and avoid 
exciting and worrying pursuits. Many of these patients would 
never come under observation at all if they had a thousand a 
year of their own and expended it properly. 

A patient who has once had an attack of the kind described in 
this chapter should for ever afterwards be weighed once a month. 
If he has lost a pound in weight, he should at once set to work to 
put it on again by allowing himself a couple of pints of extra 
milk each day. If this is insufficient, he should take extra 
rest, preferably by going to bed for a few days. Sleeplessness 
can often be averted by taking a glass of hot milk and a few 
biscuits on retiring for the night. The author is disposed to 
think that a vegetarian diet is more suitable for these patients 
than a meat diet; not that the diet should be exclusively vege- 
tarian, but that the amount of meat should be limited. 

In cases of periodic insanity wherein the patient breaks down 
at a given time of year in spite of all precautions, it is often 
beneficial to have an entire change of scene and surroundings a 
couple of months before the expected attack. If the patient 
lives in the country, let him take to a town life, and vice versa; 
or let him live in a hydropathic establishment, where the regular 
life is especially beneficial to neuropaths. 

Unless the patient is prepared to undergo psycho-analysis 
during the intervals between his attacks, he must make up his 
mind to be somewhat of a valetudinarian, ever watchful for 
prodromal symptoms, ever careful of his physical health and ever 
mindful of his last attack, even after twenty or thirty years have 
gone by. When psycho-analysis is seriously undertaken the 
doctor and patient must not be disappointed if the treatment 
has to be interrupted occasionally on account of sudden attacks 
of mania or melancholia. It must not be expected that these 


GENERAL MANAGEMENT 303 


will cease until the paralysis is complete. The patient himself 
knows perfectly well when he has got to the root of his malady 
and destroyed it for ever. 

The medical man is frequently consulted as to the advisability 
of marriage in these cases, and unfortunately there is a popular 
delusion that marriage acts beneficially on neuropaths. It is an 
obligation upon the medical man to combat this to his utmost, 
not only on account of his duty to the State to prevent, as far 
as lies in his power, the procreation of neuropathic children, 
but also in consideration of the patient. Only those behind the 
scenes can have any idea of the ruin, misery and want entailed 
by the marriage of neuropaths. I quote two cases: 

1. Husband, a dement in an asylum. Son, a ne’er-do-well 
(partial dementia after acute mania). Two daughters, typical 
alternative insanity, kept at home or occasionally sent to asylum. 
Wife keeps the home together. Daughter earns enough to help 
mother in doing this and.to keep father out of a county asylum. 

2. Wife, a nagging dement at home, the husband being unable 
to afford the means to keep her in a private asylum. Wife’s 
brother in an asylum, paid for by husband. Two daughters in 
an asylum. Daughter died in an asylum. Son, a ne’er-do-well 
(partial dementia). Husband a bankrupt, but, having a sound 
nervous system to withstand all this stress, sane. 

Nevertheless, there are cases of maniacal-depressive insanity 
with little or no hereditary factor. These are due mainly or 
entirely to circumstances, influences, situations and incidents 
which have occurred in the life-history of the individual. When 
such patients have undergone an analysis, there is no objection 
whatever to their entering matrimony and procreating children. 
In fact, their influence on the life-history of their children would 
be exemplary. 


CHAP CER SVL 
PARANOIA. 


WHEN a person is afflicted with some unfortunate trait in his 
character of which he is ashamed, he is unwilling to admit the 
fact to himself and at the same time remarkably intolerant of 
the same failing in other people. He also tends to ascribe it to 
others who do not possess it. The untruthful man is chary of 
giving credence to others, the scandalmonger supposes himself 
to be an object of gossip and the man who marries for money 
refuses to believe that love can ever- be the sole reason for 
matrimony. This mental mechanism, which plays an important 
role in every case of paranoia, is known psychologically as 
projection. In psycho-analytic terminology we would say that 
a person’s knowledge of his faults, failings and deficiencies tends 
to be repressed into his unconscious and to be replaced in con- 
sciousness by his recognizing them, rightly or wrongly, in other 
people. 

Paranoia is a psychosis characterized by systematized delusions 
which develop progressively as a result of the patient projecting 
certain of his repressed complexes upon other people. In 
hysteria the repression is converted through compromise into 
physical or mental symptoms; in the obsessional neurosis it is 
substituted ; in paranoia it is projected. Not only on single occa- 
sions, but throughout the patient’s psychotic life this mechanism 
is in constant operation, so that he permanently obtains a dis- 
torted view of his relationship with the world in which he lives, 
forms erroneous judgments and is ever on the alert for evidence 
to justify them—with the result that, from his point of view, he 
is apparently justified in the opinions he holds. Incident after 
incident is misinterpreted and the misinterpretations are woven 
into a coherent web until the whole of his mental life is in- 
extricably bound in a systematized network of delusions. 

Etiology.—The development of the disorder is so insidious 
that in most cases it is difficult to determine the age of incidence, 
but paranoia usually asserts itself during the fourth or fifth 
decade, It occurs more frequently in men than in women. A 

hE § 


SYMPTOMS OF PARANOIA 305 


history of insanity in the family may be obtained in rather more 
than half the cases. 

The patients are more often single than married and commonly 
lead a solitary life. The reason for this will appear later. 

In a few cases the repressing forces of the mind have been 
enfeebled by a previous attack of mental disease or bodily illness 
which weakens the repressing forces of the mind. The beginning 
of the disorder is sometimes referred to a definite incident. For 
example, one patient’s deterioration was said to date from an 
occasion when certain articles were stolen from the pavilion 
of his cricket club; in another case the first symptom was alarm 
at or suspicion of a certain unknown woman’s motive in staying 
unduly long at Mass in the Madeleine at Paris during the patient’s 
visit to the church. Occasionally the disorder is initiated by 
a dream which is accepted by the patient as a reality. For 
example, an unmarried female patient dreamed some eight years 
before she came under observation that she was in bed with a 
man; this dream laid the foundation for the delusions that her 
brother admitted men into her bedroom at night, that she had 
had six children and that, at the time of observation, she was 
pregnant with twins.* 

Symptomatology.—On account of the slow insidious develop- 
ment of paranoia, it is usually four to six years before the 
relatives of a patient realize that he is suffering from mental 
disorder and the advice of a physician sought. We have 
therefore little opportunity of studying the psychosis in its 
early stages. The history generally reveals that there has been 
insomnia at night and incapacity for steady work during the 
day; the patient may further have been regarded by his friends 
as eccentric but not insane. | 

When he comes under observation the most careful physical 
examination reveals nothing abnormal, with the exception 
perhaps of a certain unsteadiness of gaze which I have noted 
in many cases. 

Cutaneous sensation, vision, hearing, smell and taste are all 
normal; there is neither anzesthesia nor hyperasthesia. 

The patient is well orientated and there is no deterioration of 
the perceptive faculty. Hallucinations do not occur. On the 
other hand, there appears to be an abnormal keenness of the 
perceptive faculty. From the commonplace salutations of his 
friends he perceives that he is a greater man than he had 

* Probably I would now regard this case as an example of paraphrenia, 


but it serves to illustrate my point. 
20 


306 MIND AND ITS DISORDERS 


hitherto supposed; in some chance preoccupation of his wife 
he sees evidence of her infidelity; in a colleague’s assistance in 
his work he discerns a hint that he is neglecting his duty; in a 
flower worn by a lady he espies a sign that she is in love with 
him; in books, papers and placards he sees many hidden refer- 
ences to himself; a group of poverty-stricken children is, for him, 
a call from God that he should become a social reformer; an 
attack of breathlessness after running for a train is an indication 
that everybody, not only himself, eats too much meat. 

This excess of perception is determined by a prevailing emo- 
tional tone which varies from patient to patient—ambition, 
jealousy, love or suspicion; but apart from this there is no 
disorder of emotional reaction. 

The essential characteristic of paranoia being disorder of 
judgment, the patients have no insight into their mental 
condition. 

It has been ascertained by Cattell that association-time is 
prolonged in paranoiacs. The observation may be taken for 
whatsit is worth. I have not seen the original paper, but the 
criticism which at once suggests itself is that it is not fair to 
compare the time-reactions of the insane with those of practised 
observers in the psychological laboratory. 

The association of ideas is influenced by the patient’s customary 
emotional attitude and the whole of his mental life is dominated 
by his particular delusion. Otherwise the train of thought is 
normal; the patients are capable of carrying on conversations 
and discussions rationally, provided the topics have no reference 
to their particular delusions. Paranoiacs can play games of skill 
as well as, and often better than, normal individuals. 

The memory is good. Incidents are correctly remembered, 
although the import or meaning of these incidents may be mis- 
interpreted in after-years when the mental disorder has become 
established. 

The conduct is influenced by the delusions. The patients 
may disguise themselves so as not to be recognized by their 
supposed persecutors, they appeal to the magistrate for advice 
how to escape them or perhaps they travel about from place to 
place in order to avoid them. One patient journeyed from 
Hastings to Newcastle, stopping at many towns on the way in 
search of an unknown lady-love. Mattoids and religious para- 
noiacs often take to preaching in the public street, writing to 
the papers and distributing pamphlets in which they air their 
particular fads. More aggressive natures take up the battle 


SYMPTOMS OF PARANOIA 307 


with their supposed enemies and retaliate by every means in 
their power, even resorting to murder in some cases. Paranoiacs 
may be the most dangerous patients with whom we have to deal. 

Yet there is a class of so-called “ resigned paranoiacs ’’ who 
accept the situation of being detained in an asylum and patiently 
wait the time when the doctors and others will realize their 
mistake and set them free. It is, however, necessary to bear in 
mind that many such patients are suicidal. 

The paranoiac may be excessively garrulous; otherwise speech 
and articulation are normal. Similarly these patients are apt 
to write letters of inordinate length, not uncommonly fifty pages 
of foolscap. The letters are coherent and the calligraphy is 
unaltered. 

On the foundation of an ill-balanced temperament and dis- 
ordered perception there is erected a coherent system of delu- 
sions the import of which forms the basis of classification of 
paranoiacs. Disorder of judgment is the essential feature of 
paranoia. 

There are two large classes of paranoiacs: 


1. The eccentrics or mattoids; and 
2. The egocentrics including 


(a) Persecuted paranoiacs, 

) Exalted paranoiacs, 

c) Litigious paranoiacs, 

) Religious paranoiacs, 

e) Amorous paranoiacs, 

f) Jealous paranoiacs and 

(g) Hypochondriacal paranoiacs. 


Of the two classes the former is probably the larger; but we 
see more of the latter in asylums because egocentric delusions are 
on the whole more liable to lead a patient into open conflict 
with society and to necessitate his sequestration. 

The Eccentrics or MATTOIDS are people with wild, altruistic 
impersonal theories to which they give vent in voluminous 
books or in harangues to crowds in the open spaces of the town 
in which they live: but all their activity leads to nothing; they 
are regarded simply as faddists or cranks and no further action 
is taken. -They are full of absurd projects and utopian ideas; 
they preach pacifism, Christian Science, anarchy, revolution, 
“back to the land’’, vegetarianism, anti-this, anti-that and 
anti-the-other-thing. Some teetotallers who are anxious to 
finger other men’s souls belong to this class. Many wear 


308 MIND AND ITS DISORDERS 


pieces of coloured ribbon or some other badge that all may 
know the views they hold. Some are engaged in grotesque 
inventions; one patient went so far as to present to the Patent 
Office a specification for manufacturing gold from husks of 
corn. 

The essential characteristic of the mattoid is that his view 
of life is distorted in such a way as to lead him to exaggerate 
the importance of trivialities, in popular parlance, to “ make | 
mountains out of molehills”’. 

These are the “‘ borderland ’’ cases of insanity. 

EGOCENTRIC PARANOIACS, as the appellation implies, suffer 
from delusions in which their own personality evidently plays 
the most important réle. 

Delusions of persecution are the natural outcome of a sus- 
picious temperament. For the suspicious man there lurks in 
everyday incidents a hidden meaning of ill omen. People 
sitting at their windows are there to watch his movements, a 
carious tooth is the result of secret poison, the non-success of 
a commercial venture is the work of an enemy, policemen on 
the beat at night are keeping a special watch on his doings, 
small groups of friends in conversation are discussing his fate 
and questions in Parliament secretly refer to his evil influence 
on the State. In this way the patient gradually arrives at the 
conclusion that a secret society, such as the Freemasons, or a 
religious body, such as the Jesuits, is conspiring to do him injury. 
In other cases he accuses whole nations of plotting against him; 
in yet others the conspiracy is worldwide. On the other hand, 
some patients fix upon one particular person as being the cause 
of all their troubles, and in turn persecute him. These are indeed 
‘most dangerous patients and not infrequently carry their revenge 
as far as murder. 

Delusions of exaltation are almost certain to appear sooner or 
later in conjunction with delusions of persecution. The patient 
begins to look around for a reason why so many people should 
be interested in his downfall and some chance incident gives 
him the clue. People make way for him as he enters the theatre, 
showing that they recognize him to be a person of importance; 
a chance resemblance to a portrait of some member of the Royal 
Family proves that he is of royal descent; a person of the same 
-name inherits a fortune, clearly indicating to the patient that he 
himself is the rightful heir and that the possessor of the fortune 
has assumed his name; the congregation rises and the organ 
peals at the moment when he enters the church because he is a 


EGOCENTRICS 309 


prophet of the Lord, or he is awarded bedroom No. 3 on his 
entry into the asylum for the reason, obvious to him, that he is 
a member of the Trinity. But delusions of exaltation are not 
always a sequel to delusions of persecution; they frequently 
arise contemporaneously with or independently of such delusions. 
In some cases the patient fixes upon an accident in his remote 
past which suggests the possibility that he is a great personage. 
One patient, for example, recalled an occasion when a party of 
children at play, including himself, was stampeded by a runaway 
horse. After forty years the possibility occurred to him that, 
on being subsequently claimed by their respective mothers, 
these children might have been exchanged and that he might 
be the heir to a dukedom. Possibility became probability and 
probability became certainty that he was in reality a duke. 

Litigious Paranoia.—When a paranoiac imagines himself to 
be persecuted by a single individual he himself is liable to turn 
persecutor. He calls at the house of his victim at all sorts of 
opportune and inopportune times; and when the door is closed 
on him, as in due course it invariably is, he lies in wait for his 
supposed enemy or follows him about wherever he goes, in order 
to air grievances, to threaten him or injure him in some way, 
perhaps to murder him. He also writes threatening letters and, 
if he is a man of sufficient means, brings the case into court and 
claims damages. He loses but resolves to carry on the case and 
takes it from one court to another, squandering his money in 
litigation. These patients do not hesitate to forge incriminating 
documents and to bring them forward as evidence; they may 
even bear false witness in court to attain their ends, for it is 
characteristic of them to disguise the truth. 

They fill reams of paper in setting forth their complaints to 
persons in authority, and in speech they are voluble or even 
eloquent. Pride and self-esteem dominate their character; 
they believe themselves to be incapable of doing wrong. As a 
result they become hypercritical of the doings of others and, 
when they find themselves sequestrated in an asylum, they are 
a plague to the institution. They criticize the routine, get up 
trumpery charges against the attendants and write complaints 
against the medical officers to the Board of Control. 

Religious Paranoia.—These patients devote their attention 
to the religious side of life. They feel that they have a call 
from God to lead sinners to salvation. They become prophets, 
mystics or spiritualists and believe that they are in communica- 
tion with the unseen world. 


310 MIND AND ITS DISORDERS 


Amorous Paranoia.—In this condition we have to deal with 
a class of patient who falls in love with some member of the 
opposite sex and believes his or her love to be reciprocated, 
although the object of admiration has never wittingly given any 
justification for such a supposition. A casual glance, a change 
of dress or a flower in the buttonhole is taken to mean that 
the patient’s attentions are favourably received. He addresses 
poems and love-letters to his supposed sweetheart; and when 
they are returned and he is told in writing that he can entertain 
no hope of requital he considers that this is done to try the 
strength of his affection. Accordingly he becomes more im- 
portunate, determined and even threatening. Ultimately his 
attentions are so aggressive as to necessitate his removal to an 
asylum. 

Somewhat similar to the above are those patients who disown 
their parents and claim to be admitted into the circle of another 
family. There is also the patient who fixes upon an unfortunate 
individual and becomes the torment of his life by wishing to be 
claimed as his son. 

Jealous Paranoia.—The psychosis frequently manifests itself 
in the guise of unfounded or excessive jealousy. The husband 1s 
insanely jealous of his wife and suspects her of infidelity, the most 
ordinary happenings proving sufficient ground for suspicion: 
the sofa cushions being arranged not quite as usual or men hurry- 
ing past the window ostensibly to catch their morning train, 
but really to avoid observation by the patient ; or the wife suspects 
her husband because he is late for dinner or has joined a choral 
society or takes her to the theatre (not to see the play but te look 
at some other woman). The patient accompanies him, not to 
see the play, but to watch her husband’s gaze. It need not be 
pointed out that such marriages are very unhappy; but let the 
picture be a warning never to advise marriage to any person in 
whom you have reason to suspect a homosexual trend, conscious 
or unconscious. 

Hypochondriacal Paranoia (Hypochondriasis).—There is a small 
number of egocentric paranoiacs who project their complexes, 
not as the behaviour of others, but as that of their own organism. 
From their youth up they worry unnecessarily about the condi- 
tion of their health, exaggerate trivial abnormal sensations into 
important symptoms of some terrible organic disease, read 
patent medicine advertisements and other such publications, 
discover in themselves all the symptoms therein suggested and 
accordingly buy and take any number of quack nostrums. The 


VARIETIES OF PARANOIA 311 


condition is progressive and the patients may finally reach a 
state in which they believe day after day, year in and year out, 
that their last hour has come in spite of their perfectly healthy 
aspect and reassurances from their friends. They constantly 
want the doctor to examine them in the hope that he may be 
able to discover some other cause of their wretched condition 
than disease of the imagination. In reality they are in good 
physical health and inordinately fat; for their appetite, of which 
they take full advantage in order if possible to keep themselves 
alive, is enormous. 

Some of these patients rail at the doctors for not paying 
more attention to their case, for not discovering the cause of 
their illness or for giving them the wrong medicine. Some even 
ascribe their condition to a particular bottle of medicine which 
he gave years ago. Then they become querulant paranoiacs, 
persecute their doctor, threaten him, sue him for damages in a 
court of law or even make attempts on his life. Hypochondriacs 
sometimes attempt suicide, not to end their misery, but to draw 
attention to their case. They do not as a rule intend that the 
attempt should be successful, but occasionally it is. Under 
such circumstances the jury returns a verdict of suicide whereas 
the truth of the matter is that death was accidental. 

Diagnosis.—Paranoia is recognized by the slow, insidious 
nature of its beginnings and the chronic progressive systematiza- 
tion of the delusions on which the patient bases the whole of 
his mental life. It is to be distinguished from the somewhat 
similar delusional states occasionally arising as a sequel to 
attacks of intermittent insanity by the definite history of an 
attack of mania or melancholia in the latter. Should the patient 
have been seen before the physical signs of mania or melancholia 
have disappeared, there can scarcely be any difficulty in the 
diagnosis. 

Dementia paranoides is distinguished by a more rapid onset, 
the presence of mannerisms, negativism and other signs of 
dementia preecox and also by persistent hallucinations and 
their important réle in determining the character of the 
delusions. 

Paraphrenia is differentiated by the coexistence of hallucina- 
tions. They are usually present before the patient comes under 
observation. If not, the diagnosis may be difficult. 

General paralysis, which may occasionally present symptoms 
suggestive of paranoia, may be recognized by the characteristic 
physical signs of that disease. 


312 MIND AND ITS DISORDERS 


Prognosis.—Paranoia is a hopelessly progressive condition with 
no tendency to dementia. There is but little hope of recovery. 

Pathological Anatomy.—There is no true morbid anatomy of 
the psychosis, but it has been said that congenital modification 
in the arrangement of the cerebral convolutions 1s sometimes 
to be found and, according to Morselli, an increase of the con- 
stituent elements of the association. areas. 

Some of the patients exhibit physical stigmata of degeneration, 
especially physical characteristics of the opposite sex. 

Psychopathology.—Freud was the first (about 20 years ago) 
to discover and elucidate the fact that a certain case of paranoia 
(that of Dr. Schreber, who published his own autobiography) 
was erected upon a basis of repressed homosexuality and since 
that time it has gradually become established that this is the — 
invariable foundation of the disorder. Homosexuality is 
naturally repugnant to everybody and particularly to most 
people who have homosexual tendencies themselves. They 
refuse to believe that they are especially attracted to members 
of their own sex and repress the idea into the unconscious; but 
should the repression fail, the complex tends to assert itself in 
delusional disguise—as paranoia. The psychical mechanism by 
which this transition takes place is as follows: 

The paranoiac always starts with the unconscious premise 
‘“T love the man ’’ (for convenience I am assuming the patient 
to be a male). 

Persecuted Paranoia.—‘‘I love the man’’—an_ intolerable 
idea, therefore becoming repressed and replaced in consciousness 
by “Ido not love him; I hate him”. This by projection becomes 
‘““ He hates me ’’, “‘ I am persecuted by him’”’. 

Exalted Paranota.—“ I love him ’’—again an intolerable idea, 
therefore “ I do not love him, I love myself ’’. This by projection 
becomes “‘ Everybody loves me”’, “‘ I am a great person ”’. 

Religious Paranoia.—“ I love him ”’ being intolerable, becomes 
“ T love Him ”’ (spelt with a capital H), meaning “‘ I love God ”’. 
This by projection becomes “‘ God loves me ’’, “‘ I am the chosen 
one of God ”’. 

Amorous Paranoia.—tThe intolerable ‘“‘I love him’’ becomes 


‘““T do not love him, I love her’’. This by projection becomes 
““ She loves me ”’. 
Jealous Paranova.—“ I love him’”’, as usual, is replaced by “ I 


do not love him; she loves him ’’. 
Hvpochondriacal Paranoia is somewhat like exalted paranoia, 
‘“ T love myself ’’ becoming “ I must take care of myself ”’. 


TREATMENT OF PARANOIA 313 


Querulant Paranoia is only a special variety of persecuted 
paranoia. 

Treatment.—Medicines are of course useless and most para- 
noiacs have to be sequestrated in a mental hospital, not so 
much for their own sake as for the convenience or even safety 
of the general public. Some, however, welcome the asylum as 
a safe harbour of refuge from their supposed persecutors. 

Although psycho-analysis has succeeded in elucidating the 
psychology of this disease, it all but fails as a method of treatment. 
The patients very rarely have insight and are therefore unwilling 
to co-operate with the physician who seeks to cure them of what 
they believe to be a non-existent malady. It is not uncommon, 
however, in psychological practice to come across a neuras- 
thenic with paranoid tendencies and presumably a potential 
paranoiac who becomes perfectly normal after a course of psycho- 
analysis. During the last few years indeed some psycho-analysts 
have had a certain measure of success with some very early 
paranoiacs. 

But we have not shot our bolt on this problem; there are other 
methods of tackling it. For example, the physician who is to 
attempt to effect a recovery should be forearmed before he has 
his first interview with the patient. He must accept the patient’s 
point of view from the first and encourage him to give a detailed 
history of his case. The doctor must remain ostensibly unbiased. 
While refuting absolutely nothing that the patient tells him, 
it is not required that he should openly accept the delusions as 
facts. This first stage consists of leading the patient to the 
conviction that he has a sympathetic listener. In due course 
an occasion arises (after many hours of conversation) when the 
medical man has an opportunity of suggesting, in respect of some 
quite minor detail, that his patient may have been mistaken. 
Although it is essential that the doctor should understand the 
psychology of paranoia, he makes no attempt to get the patient 
to penetrate his own unconscious mind. He is merely on the 
alert for minor misinterpretations and tries to correct them. 
As time goes on, an opportunity occurs for suggesting that the 
patient may have been mistaken in a matter of rather more 
importance and ultimately it may be found possible to deal 
with the main delusions. Appropriate fragments of psychology 
are occasionally introduced; but the whole procedure requires 
an extraordinary amount of tact, for a single false move is fatal 
to the patient’s confidence and therefore to success. 

Another method is, after similarly gaining the patient’s con- 


opel MIND AND ITS DISORDERS 


fidence, to develop an attitude of resignation in his mind so 
that, although he retains his delusions, he pays no ostensible 
attention to them, is prepared to let bygones be bygones, 
allows people to think that they are non-existent or, at any 
rate, that he does not act upon them and goes about his work 
like a normal person. This procedure also requires very careful 
and tactful handling. Quite a number of these patients can 
ultimately pass muster in the outside world with a little financial 
assistance. 


COMMUNICATED INSANITY. 


FoLiE A DEvUxX. 


This is a state of affairs in which two, or sometimes more, 
people intimately associated with one another mutually develop 
what appears to be identically the same mental disorder, usually 
delusions of persecution. The subsequent history of these 
patients usually discloses the fact that one of them is a paranoiac 
and has induced the other to believe in his delusions; in other 
words, he has communicated his insanity to the other. In order 
that this should happen it is essential that the two patients 
should have been intimately associated, should have many 
interests in common, view life from similar standpoints and 
have isolated themselves from the outside world. Accordingly 
we find that folie a deux usually occurs in two members of the 
same family, sisters, brothers, father and son, mother and 
daughter or perhaps husband and wife. 

It must be understood that the occurrence of insanity in two 
members of the same family as a mere coincidence at the same 
time does not necessarily constitute a case of folie ad deux. It is 
essential that the mental disorder of one patient shall be directly 
due to the persuasive influence of the other. For example, 
when a woman becomes maniacal on account of the mental 
anxiety caused by nursing a maniacal sister, that is not a case 
of communicated insanity, because it is not induced by the other 
patient’s persuasive influence. 

It is said that the delusions are as a rule not so strong in 
one patient (the passive element of the couple) as they are in the 
other (active element). With this statement I cannot agree; for 
it is quite impossible, when such a couple comes under observation, 
to discern any mental differences between them and therefore to 
determine which is the active element and which the passive. 

The following is a good example of communicated insanity: 


COMMUNICATED INSANITY 315 


Two unmarried sisters, aged respectively twenty-six and 
thirty, lived together in a small house in a London suburb. 
Gradually they came to neglect their social duties, failed to call 
on their friends and, as a natural result, did not receive visits 
themselves. Then they felt neglected, thought that their friends 
wished to have nothing to do with them, that some scandal 
concerning them was rife, that they were being persecuted and 
that they should come to some harm. At this stage they drew 
up the following document. It was written by the passive 
element: 

“ September 25, 1905. 

“I, A. B. C., and I, D. E. C., do swear that the statement 
written below is the truth, the whole truth and nothing but the 
truth. If anything happens to us by violence, it will be by the 
instigation of the Rev. F’. G. H., through his agents and the 
Secret Society to which he belongs. We have been hunted down 
since the year the Queen died by the aforesaid agents systematic- 
ally day after day, week after week, taking our name away and 
shutting all doors on us. The reason of this is that his methods 
and their methods are criminal, and they have used them on us 
uselessly until to-day, when I called at Vicarage and now 
the verdict has gone forth to two next-door neighbours: the 
I, J.’s and their servant K. L., who are in their pay, given to 
them by old M., who, I conjecture, is one of their chief agents, 
and who I only imagine is largely responsible for the N. suicide— 
their aim is money and power; they have marked all the rich 
families in England with ‘XX’ to my knowledge, to marry 
crooked-mined [? minded] women to straight men running to 
kill them, then the money falls into their hands. I have been 
told to emigrate for a year to South Africa and then return, 
but there would be no return. 

““M.’s son set off a raid against us last Tuesday to Q—— 
[a neighbouring suburb]. 

“The murder in to-day’s paper was no suicide on the Brighton 
lime? 


Matters were brought to a climax when on a certain day 
these patients expected their house to be attacked. At I a.m. 
they heard a noise, threw up their windows and shouted for the 
police. The police arrived and tried to force an entrance, but 
the two sisters kept them at bay for two days with a couple of 
ancestral cavalry swords. The police were ultimately successful 
and the patients were placed under care. 


316 MIND AND ITS DISORDERS 


They were put into separate wards, but for many months 
were so reticent about the whole affair that it was impossible 
to say which was the worse of the two. The younger sister 
recovered in ten months, the elder is still under care. 

The prognosis is good for the passive element; but the active 
element, being usually a paranoiac, does not recover. It is 
impossible during the early stages to determine which patient 
is the active element, which the passive and pric beset which 
patient is going to recover. 

Treatment consists of separating the two persons and attending 
to their general health. The separation must be continued after 
recovery because the passive element is for long afterwards 
under the dominion of the active, without either of them being 
consciously aware of the fact. 


CHA li heise 
DEMENTIA PRECOX. 


DEMENTIA PRACOX is provisionally regarded as a psychosis, which 
makes its appearance in specially predisposed persons usually 
between fifteen and thirty years of age and rapidly leads in the 
great majority of cases to a profound and distinctive type of 
dementia. It comprises a very large number of cases, about 
one-eighth of the admissions to asylums, and it is characterized 
by a large number of symptoms, many of which may be regarded 
as being almost pathognomonic of dementia precox. Its recog- 
nition is mainly due to Professor Kraepelin of Munich. 

Etiology.—The history of patients suffering from this disorder 
usually discloses the fact that they come of an insane stock, 
generally on the maternal side, and frequently that theirs is not 
the first case of dementia preecox in the family. It has been said, 
apparently with some truth, that the children of general paralytics 
are specially predisposed to dementia precox. Nor have signs 
of mental instability been wanting in the patient: as a rule, he 
has not done particularly well at school, he has been seclusive 
and impulsive, unduly devoted to religious exercises, emotional 
and easily susceptible to the influence of alcohol. Some patients, 
on the other hand, display considerable mental ability in early 
life. 

Physical stigmata are common, such as deformities of the 
pinne, palate, hair and hands. The author has observed a 
deformity in the patient’s hands, assimilating them to those of the 
apes, especially of the chimpanzee, and to those of the lemurs. 
The hands are in many instances long, thin and delicate, with 
flattening of the thenar and hypothenar eminences; the thumb 
looks more or less forward like the other digits, being rotated 
outwards instead of looking across the palm. If the terminal 
phalanx of the thumb be flexed, it may be observed that it fails 
to undergo the normal amount of internal rotation on the proximal 
phalanx. This peculiarity also is to be seen in the apes. Another 
common feature is abnormal laxity of the ligaments of the 
metacarpo-phalangeal joints so that the fingers can be passively 
hyperextended, almost to a right angle. 

317 


318 MIND AND ITS DISORDERS 


These characteristics, taken in conjunction with the facts that 
they are sometimes encountered in cases of idiocy, especially 
those of the Mongol type, that imbeciles are liable to develop at 
puberty symptoms resembling those of dementia precox and 
that the above peculiarities of the hands are also to be observed 
in the chimpanzee all point to the conclusion that dementia 
precox may be regarded as a failure in evolution, as an atavism 
or reversion to an ancestral type. 

Such a view is corroborated by the statements of the parents 
of many of these patients. Some go so far as to say that there 


% 


35 


350 


25 


20 


10 15 20 25 30 35 40 45 50 55 60 


4, 3-5|27 [217 |255]228|:50|5-0|3-3]1-2 |r jo-z 


Fic. 48.—AGE-INCIDENCE OF DEMENTIA PRA&COX 
(AFTER KRAEPELIN). 


is nothing the matter with the patient, others say that he was 
always in a somewhat similar condition; and one exceptionally 
observant and intelligent mother volunteered the remark that 
no new symptoms had ever developed in her daughter, she had 
but “ gradually become more and more herself ’’. 

Nevertheless we are bound to admit that atavism does not 
entirely account for all the features of this disease. The rapidity 
of the deterioration, the physical ill-health and the possibility 
of recovery, though rare, all seem to indicate that some active 


DEMENTIA PR#COX 319 


morbid process is at work. Further, Alzheimer and others have 
demonstrated that, in certain cases of dementia praecox (kata- 
toniacs), there are isolated areas of gliosis in the deeper layers 
of the cortex. In view of the fact that incidence of most of 
these cases is at the age when the sexual functions are most 
active, it has been suggested that this disease is due to defective 
internal secretions of the ovaries and testes. Other evidence 
relating to this matter is given in the section on morbid anatomy 
and pathology on page 341. On the other hand, there may 
be some purely psychological explanation. 

Pighini, in his studies of the metabolic processes in dementia 
precox, found that there is increased elimination of nitrogen 
and phosphorus during acute stages and diminished elimination 


Fic. 49.—SIMIAN HANDS OF DEMENTIA PRAECOX. 


of these elements in advanced stages of the disease. From 
these discoveries he concluded that there is destruction (or loss) 
of nucleo-proteids in the acute phases. These observations 
point in rather the same direction. 

It is also stated that the cerebral cortex from cases of dementia 
preecox is characterized by deficiency of organic and excess of 
inorganic sulphur. Berger discovered that the blood-serum of 
katatoniacs injected into the posterior lobes of the brains of dogs 
caused muscular spasms, apathy and a tendency to constrained 
attitudes. This also argues in favour of the auto-intoxication 
theory. 

Jung claims an exclusively psychical origin of the disorder. 
By his special method of psycho-analysis he has been able to 


320 MIND AND ITS DISORDERS 


reveal repressed complexes and conflicts, almost invariably of 
a sexual character. He admits the evidence in favour of the 
auto-intoxication theory; but points out that the toxins may 
quite well be produced as a result of mental conflicts. Con- 
sideration of the anxiety neurosis and exophthalmic goitre 
lend support to such a view and I have had patients whose 
physical appearance was altered by psycho-analysis (develop- 
ment of the breasts and blanching of the hair for example). 
Apart from the difficulty of psycho-analysis in dementia 
preecox, this process is of little or no therapeutic value for 
this disease. 

Physical Signs.—At the onset of dementia praecox the patients 
are found to be in poor health and ill-nourished. The pulse is 
frequent, sometimes irregular and usually of low tension; in 
depressed cases the arterial tension is raised. Dr. John Turner 
of Brentwood Asylum found the blood-pressure raised in 30 per 
cent., lowered in 30 per cent., and normal in 40 per cent. The 
skin is often greasy and the complexion sallow. The appetite is 
poor, the bowels constipated and menstruation is usually in 
abeyance. In katatoniac stupor the extremities are often cold, 
the hands are cyanosed and there may be cedema of the hands, 
feet and face, especially about the nose and lips. 

Dide and Chénais examined the blood of 18 patients. They 
found the number of polymorphonuclear leucocytes to be dimin- 
ished in 5, increased in 4, and normal in g. Dr. John Turner 
found hypoleucocytosis in 5 out of 6 cases. Dr. Lewis Bruce, on 
the other hand, found hyperleucocytosis in all cases of hebe- 
phrenia and katatonia; but the polymorphs dropped to 50 per 
cent. or less “1” a few incurable cases’ (sic). 

Occipital headache is a common complaint, especially of those 
patients who suffer from amenorrhcea. The hair is often erect 
and frequently there is transverse wrinkling of the forehead which 
differs from that of melancholia in that it is not limited to the 
centre of the forehead but carried out beyond the supra-orbital 
ridges, thus causing an expression of surprise or wonder; the 
wrinkles are also higher on the forehead than in melancholia. 
The pupils are usually dilated but react well to light. Tremor 
of the closed eyelids occurs in many cases. The tendon reflexes 
may be greatly exaggerated, more than in any other form of 
insanity. A tap on the patellar tendon causes a knee-jerk of 
wide excursion, followed by a very brisk return due to contraction 
of the semimembranosus and, in some katatoniacs, by rectus 
clonus. The superficial reflexes are normal. 


PHYSICAL SIGNS OF DEMENTIA PRECOX 321 


The rigidity which occurs in some cases of katatonia differs 
from that of melancholia in its distribution. In melancholia the 
rigidity affects the large proximal joints most; in katatonia the 
rigidity is uniformly distributed. 

All these physical signs are limited to the acute stage of the 


Fic. 50.—ERECTION OF THE HAIR IN DEMENTIA PRAECOX. 


disease. As a rule they disappear as the patient puts on flesh 
and becomes restored to good general health. 

If a simple finger movement (flexion and extension) be recorded 
on a revolving drum, the tracing usually shows a flattened top 
indicating a pause between flexion and extension—as if the muscle 
were poisoned with veratrin. Figures 51 and 52, kindly made for 
me by Dr. Hewart at Bethlem Royal Hospital, show the difference 


FIG. 51.—NORMAL MUSCLE CuRVE. 


between a normal muscle curve and one obtained from a patient 
suffering from dementia paranoides. 

Mental Symptoms.—Patients suffering from katatoniac stupor 
may have peripheral anesthesia. In many cases the hands only 


are anesthetic; in others the loss of sensation involves the whole 
21 


322 MIND AND ITS DISORDERS 


of the limbs and trunk, with the exception of a small area in 
the neighbourhood of the groins. Kraepelin believes the lack 
of response of these patients to a pinprick to be a negativistic 
sign, the patient simply taking no notice of the prick. The 


Fic. 52.—DEMENTIA PRACOX CURVE, 


present author contends that there is true anesthesia, if only for 
the reason that the loss of sensation has a definite distribution. 

Perception and orientation are good. Hallucinations, especi- 
ally of hearing, occur in the acute stage of the disease, but they 


FIG. 53.—WRINKLING OF THE FOREHEAD AND ERECTION 
OF THE HAIR IN DEMENTIA PRACOX, 


This type of wrinkling is of bad prognostic significance and, in another 
class of case occurring in later life, may be especially helpful in 
determining whether a given presenile case is one of anxietas presenilis 
or a more curable form of melancholia. 


may disappear as dementia supervenes. In the majority of 
cases the hallucinations are, as in most insanities, as vivid as 
real percepts; but it is especially in dementia precox that faint 


MENTAL SYMPTOMS OF DEMENTIA PR#COX 323 


mental images are experienced which lack the vividness of true 
hallucination and have accordingly been named, not very happily, 
pseudo-hallucinations or psychical hallucinations. The patients 
realize that these faint mental images differ from ordinary 
thoughts in that they are not referred to the environment, not 
eccentrically projected. 

Cognition and recognition of familiar faces and common objects 
are quite good, but most of the patients are unable to form a good 
concept of unusual objects. For example, on the production of a 
Galton’s whistle for purposes of testing a case of dementia przecox, 
the patient remarked: ‘‘ What a pretty thing! Did you pick it 
up in the grass?’’ At the time we were in a part of a ward 
whence no grass could be seen, and on the instrument there was 
no sign of rust to suggest that it might have been lying in a 
damp place. 

Similarly memory is unimpaired, at least for recent events; 
but it has appeared to the author that the memory for remote 
events is sometimes confused, because there is occasional incon- 
gruity in the patients’ statements about events long past. For 
example, one woman stated that she had been married thirteen 
years, that her marriage took place in 1895, that her eldest child 
was born a year after marriage and that he was now eleven years 
old, the year at that time being 1905. 

With such slight impairment of recent memory, cognition and 
recognition, it might be supposed that there is little disturbance 
of the association of ideas, but this is far from being the case. 
The majority of these patients display striking poverty of 
thought; they sit still in the midst of the most fantastic environ- 
ment and apparently think of nothing. 

This apathy to their surroundings is but a part of a general loss 
of emotional reaction. The patients settle down to asylum life 
without evincing the slightest care or resentment at having been 
cut off from the outside world; they have no anxiety or fear 
for the future, no satisfaction or regrets for the past; joy and 
sorrow, love and anger they know not and attention is at its 
lowest ebb. That this apathy is real, and merely apparent by 
reason of suppression of all outward manifestation of affect, is 
clearly demonstrated by the weakness of the “‘ psychogalvanic 
reflex "’ in dementia precox; it is even completely absent in 
many cases of katatoniac stupor. 

It is true that some patients vociferously demand, at every 
visit of the doctors, to be set at liberty; but the request is rather 
an act of negativism or stereotypy, often initiated by hearing 


324 MIND AND ITS DISORDERS 


another patient ask for release, than the expression of an emo- 
tional desire to go home. One such patient, a lady in Bethlem, 
used to demand daily’ to be let out to a workhouse or convent, 
anywhere, be the surroundings never so objectionable, but always 
with a smile on her face. Another lady used to make frequent 
inquiries as to the whereabouts of her mother, but they were 
lacking in emotion and gave an onlooker the impression that they 
were put merely for the purpose of saying something. 

Similar remarks are applicable to the imstincts of patients 
suffering from dementia precox. They are seclusive, have no 
desire for outdoor pursuits, are not often erotic, rarely make 
collections of objects and, when such a collection is made, it is 
an example of stereotypy; one such patient, for instance, would 
stitch useless articles to a piece of flannel. 

When they become destructive their destructiveness is an act 
of negativism rather than blind instinct. They tear their clothing 
or injure fellow-patients merely because they know that they 
should not do so. At the same time we have to realize that 
negativism itself is instinct gone astray. 

The most striking feature of dementia pracox is disorder of 
conduct. 

The disorders of conduct characteristic of and almost peculiar 
to this disease fall under two heads: 

(a) Catalepsy, a state in which there is blind unconditioned 
obedience to suggestion from without ; and— 

(b) Catatonia,* a state in which acts are performed, not as 
a final sequel to a play of motives but as a response to some 
unrecognized purely organic stimuli to which a corresponding 
psychical state is normally wanting; in other words, catatonia 
is a state in which there is blind unconditioned obedience to 
abnormal stimuli from within. 

Catalepsy includes such symptoms as flexibilitas cerea, auto- 
matic obedience or imitativeness (echopraxia and echolalia) and 
negativism. 

Flexibtlitas cerea (waxy flexibility) is a condition in which 
the limbs can be easily moulded into unusual positions and 
remain in those positions for some considerable time, perhaps 
half an hour or more. In some cases the limb will remain in a 
given position for only ten or fifteen seconds; there is then said 
to be a tendency to flexibilitas cerea. 

Echopraxia is a disorder of volition in which the patient 


* Catatonia, the symptom, is distinguished from katatonia, the disease, 
by a difference in spelling. 


NEGATIVISM 325 


imitates any action performed in front of him. If the doctor 
stands on one leg, the patient does so too; if the doctor waves 
his arm in the air, so does the patient. Such an one may also 
imitate the antics of any other patient near him. 

Echolalia is the same symptom in the domain of speech. 
Whatever is said to the patient he at once repeats; if he is asked 
a question he simply repeats it, with or without a change of 


te * 
4 


Fic. 54.—DEMENTIA PR&COX: FLEXIBILITAS CEREA. 


pronoun, without giving any answer. If the doctor asks, ‘‘ How 
are you to-day ?”’ the patient replies “‘ How am I to-day ?”’ 
Cataleptic Negativism is a state in which any suggestion given 
to the patient immediately arouses the counter-suggestion. If 
he be asked to protrude his tongue he closes his lips firmly; if the 
dinner-bell rings he walks away from the dining-room; when 
dinner is over it may take four attendants to remove him from 
the room, so active is his resistance; is it time to go into the 
garden it requires four attendants to get him there; is it time to 


326 MIND AND ITS DISORDERS 


come in again it needs four attendants to return him to his ward. 
At bedtime he has to be undressed by force and in the morning 
he has to be dressed again by force; if an attempt be made to get 
him to talk he remains silent; if told to remain silent he may 
respond by shouting down any conversation in the vicinity. 
Such patients occasionally strip, tear their clothes, break windows 
and furniture or strike other patients, simply because they are 
not wanted to do so. One such patient, on being given a new 
suit of clothes, was told inadvertently by the attendant not to 
tear them up: he tore them up immediately. Subsequently he 
improved and told me he would not have thought of tearing his 
clothes but for the attendant’s suggestion. 

Negativism may sometimes be beautifully demonstrated in 
cases of catatonia major by placing one’s hand near that of the 
patient as if to touch it; his hand moves away. If now the 
observer’s hand be transferred to the other side of the patient’s, 
the latter moves back again in the opposite direction like a needle 
repelled by a magnet. In this way the hand may be made to 
swing to and fro, always moving away from the hand of the 
doctor. Similarly if the doctor pretends that he is endeavouring 
to avoid the patient’s hand touching his own, the patient’s hand 
follows his, the former being constantly attracted as if by a 
magnet. 

This symptom is not to be mistaken for obstinacy or resistive- 
ness, such as occurs in resistive melancholia. That negativistic 
behaviour is accompanied by no disinclination or aversion may 
be learned from patients who have recovered from the condition. 

There are two varieties of eatatonia, major and minor. 

Catatonia major is a condition in which the patient stands 
rigidly in the same position from morning till night, provided he 
is undisturbed. He behavesas a statue, but he is not statuesque. 
Being unemotional, he does not strike attitudes like a maniac. 
He stands like a dummy, mucus flowing from his nostrils and 
saliva drooling from the corners of his mouth. 

Catatonia minor includes negativism, stereotypy, verbigeration 
and the so-called mannerisms of dementia przcox. 

Cataleptic Negativism is a state in which suggestions arise 
counter to the patients’ own wishes. They will retain their urine 
and faces, although it causes them pain to do so. They try to 
speak, but they cannot get their words out; all day long a patient 
may repeat “‘ J—I—I-—I ” trying to say something more, 
but the something more never comes. This is one form of 
verbigeration. 


MANNERISMS OF DEMENTIA PRECOX 327 


The mannerisms, tricks or antics of dementia przecox, appar- 
ently meaningless, must of course have a symbolic meaning of 
some sort; but this is difficult and usually impossible to discern. 
Without motive the patient walks up and down the same patch 
of ground, perhaps holding one arm stiffly and swinging the other. 
If anyone happens to be temporarily engaged on a portion of his 
parade-ground, he marks time until the person has moved out of 
his way; if he is caught in an unguarded moment in a secluded 
spot, he is found attempting to stand on his head; if he isasked 


Fic. 55.—IKATATONIAC ANTIC., 


The patient was accustomed to stand in this attitude and 
to wave one hand, 


to rise from a sitting posture, he does so with stiff legs, without 
bending his knees; or he may fall on all fours from the sitting 
posture. As he paces the ward he turns aside to touch objects 
(one form of “‘ folie de toucher’’); he may stand persistently 
on one leg or hyperextend his trunk till he is able to see the 
ground a few feet behind him. If asked why he has done any 
of these things, he admits that he does not know; at most 
he will say that it is the Lord’s will that such things should 
happen. 


328 MIND AND ITS DISORDERS 


An incident in my own experience throws some light on the ~ 
nature of these movements. While talking to a female patient 
suffering from dementia preecox (paranoid form) she shrugged 
one shoulder. I asked her why she had done so and she replied 
that she did not know. “It must have been the underground 
electricity.”” A moment later, unconsciously I crossed one leg 
over the other; she asked me why I had done this. I had no 
reply, I did not know; and the patient informed me that my 
action, like hers, was due to the underground electricity. From 
this we may learn that these mannerisms are unconscious in- 
stinctive acts. 

Watch a chimpanzee at the Zoo. He turns a somersault, 
climbs to the top of his cage, swings diagonally across it to a 
stump of a tree, slides down the stump and arrives at the spot 
whence he started. Why does he do this? Partly on account 
of the blind instinct of locomotion. But why did he take this 
particular course ? The chimpanzee himself could not tell, even 
if he had the faculty of speech. So it is with the mannerisms of 
dementia precox. They are perhaps monkey tricks, bearing 
evidence of the atavistic nature of the disease. 

Storch of Tiibingen has made interesting comparisons between 
primitive archaic forms of inner experiences and thought with 
those in dementia preecox. A translation of his work is published 
in the Nervous and Mental Disease Monograph Series (No. 36). 

Mannerisms may also be noted in the speech and writing of 
these patients. They articulate with unwonted precision, use 
stilted modes of expression and converse as if they were making 
a speech. If one bids them ‘‘ Good-morning ”’ at five minutes 
past twelve they reply “ Good-afternoon’’, and they correct 
others in trivial errors of speech. Stilted modes of expression 
are also used in their letters, which are frequently addressed to 
great personages, often with the most absurd request. One 
patient (an Englishman) used to write to the German Emperor, 
requesting him to bring the German army over to England to 
fetch him out of Bethlem Hospital (this was before the War); 
another (a Protestant) would write to the Pope, offering himself 
as a mainstay of the Roman Catholic Church. It sometimes 
gives us food for thought when we encounter some of these 
symptoms in apparently normal people. 

One of the most frequently observed mannerisms is the 
characteristic handshake. The hand is held out stiffly and 
straight, and frequently the handshake is scarcely over when the 
hand is rudely withdrawn as if to avoid any expression of cor- 


HANDSHAKE IN DEMENTIA PRACOX 329 


_diality. With hebephreniacs these features may vary from day 
to day, the handshake being most characteristic when the patient 
is at his worst. 

The calligraphy also is altered; half the words of a letter are 
underlined; in some letters curious illustrations are profuse and 


Fic. 560.—HANDSHAKE, 


Left—normal. Right—dementia precox. 


the writing is grotesque in some way or other; for example, 
it is penned inversely so that it can best be read by the aid of a 
mirror, or the several letters of each word are superimposed 
on one another (a form of pseudographia) or they are ex- 


I'iGc. 57.—HANDSHAKE OF DEMENTIA PRAECOX. 


travagantly long so that they are best read by turning the page 
edgewise. 

Pseudolalia, another symptom of dementia przecox, is de- 
scribed on p. 159. 

Stereotypy is the name given to the repetitive movements of 
certain of these patients. They perhaps walk continuously over 


‘ 


340 MIND AND ITS DISORDERS 


the same patch of grass, round and round in a circle or figure of 
eight, swing the arms to and fro above their heads for several 
minutes at a time or, like mechanical toy-soldiers, flex alternately 
their right and left arms at the elbow. 

Verbigeration is the same symptom occurring in the domain of 
speech. Phrases, sentences or short rhymes are continuously 
repeated for hours together. The following are some examples 
which have occurred in the author’s experience: ‘‘ Will that be 
all right if I walk up to the door and back again ? Will that be 


USL LANS Dg 
ARLE OS 


FIG. 58.—PsEUDOGRAPHIA. 
Portion of a letter by a patient suffering from dementia precox. He was 
a sergeant and the disorder was ascribed to war-shock. The letter 
was signed correctly. 


all right if I walk up to the door and back again ? Will that be 
all right if I walk up to the door and back again ?’’ and so on 
ad infinitum. ‘“‘ Our own well, pussy’s in the well; who put her 
in? Put her in ag’in. Our own well, pussy’s in the well; who 
put her in? Put her in ag’in. Our own well, pussy’s in the 
well...’ and so on. A patient who developed the stereotyped 
antic of keeping her toes in constant movement while in bed, had 
the following verbigeration: “‘ I can’t keep on twiddling my toes 
like this for ever, I can’t keep on twiddling my toes like this for 
ever, [icant keep on 3.) 6Les etcan 


* The last patient quoted was depressed and made a complete recovery. 
She was possibly a maniacal-depressive case, the “‘ twiddling”’ of the toes 
being nothing more than a compelled peripheral movement of “‘ agitated 
melancholia ’’. 


PSYCHOLOGY OF DEMENTIA PRACOX Sb 


With some patients only words or syllables are repeated. In 
such a case the verbigeration resembles stuttering or stammering. 

The judgment is frequently disordered so as to give rise to 
delusions, especially in patients who are subject to hallucinations. 

They may believe themselves to be watched or followed, 
have delusions of persecution or exaltation or accuse themselves 
wrongfully of past misdeeds. There is in fact no form of delusion 
which may not arise in the course of dementia preecox; but as 
mental deterioration and physical improvement proceed and the 
patient becomes an apathetic dement these delusions recede into 
the background and become forgotten, as do most symptoms of 
the disease. 

Psychopathology.—A broad view of dementia pracox gives 
the impression that it is the fulfilment of an unconscious desire of 
the patients who suffer from it to retire from the world of reality 
to a world of their own creation. Hence they are said to be 
“introverted ’”’. This wish to retire from the world into which 
they have been born is in many cases exemplified by a tendency 
to rest on “ bearing ”’ or “ carrying ”’ articles of furniture, which 
in psycho-analytic experience we learn to be symbols of the 
mother, or to creep into the solitude of small rooms, cupboards 
or cavities, symbolical of the intra-uterine situation; some even 
assume a prenatal attitude. The mother’s uterus is the most 
comfortable place anybody has ever experienced. 

So far as the receptive aspects of the mind are concerned, 
there appears on the whole to be little disturbance. Perception, 
cognition and recognition, ideation and memory are all fairly 
good. The defect is mainly in the efferent functions; emotion 
is paralyzed, while instinct and volition are ill-directed. The 
patient performs extraordinary actions which appear to be 
neither instinctive nor reflex; yet he tells us that they are beyond 
the control of his will (that is—unconscious). It has therefore 
been suggested that in this disease there is dissociation between 
the afferent and efferent functions of the cortex. This view 
receives support from the pathological discovery of Alzheimer 
that there is gliosis of the deepest layers of the cortex, since 
Lugaro has decided by a process of exclusion that the function 
of the polymorphous cells of these deep layers is that of associat- 
ing efferent with afferent impulses. 

Stransky considers the essential psychical feature of dementia 
precox to be a lack of co-ordination between the receptive and 
affective functions of mentation, which he calls respectively 
the ‘“‘noopsyche”’ and the “ thymopsyche’’. He calls this 


332 MIND AND ITS DISORDERS 


characteristic intrapsychic ataxia or noo-thymopsychic ataxia. 
Accordingly the names ‘‘ Dementia sejunctiva’’ and “ Schizo- 
phrenia ”’ have been suggested for this malady. 

Clinical Varieties—The various forms of dementia precox 
merge imperceptibly into one another, so that it is frequently 
difficult to refer a given case to any particular one of the varieties 
although the diagnosis of dementia preecox may be obvious. 

Four varieties of the disease are recognized: 


1. Simple dementia przecox. 
2. Hebephrenia. 

3. Katatonia. 

4. Dementia paranoides. 


Simple dementia preecox occurs in congenitally weak-minded 
children before the twentieth year. It consists of a progressive 
deterioration of the mental faculties, which is unaccompanied by 
states of depression, excitement, stupor, delusion or hallucina- 
tion. It is most frequently seen in idiot asylums. The patients 
grow apathetic and idle, unable to concentrate their attention 
upon customary pursuits and become demented in a year or less 
from the onset of the disease; their activity is characterized by 
mannerisms, negativism, Se daa and echolalia. This form of 
dementia przecox is rare. 

Hebephrenia, which is more common in men than in women, 
usually makes its début before the twenty-fifth year. Two 
sub-classes are to be distinguished; in one the chief symptom is 
mental depression, while the other is characterized by motor 
restlessness. 

The depression of hebephrenia is commonly ushered in by such 
premonitory symptoms as headache, general malaise and failure 
of nutrition. The patient becomes shy, seclusive, solitary, 
moody and depressed. He does not associate with his fellows, 
loses all energy and desire for work and feels tired of life. Hence 
determined attempts at suicide are frequent in this early stage 
and the mode of suicide is rather liable to be somewhat bizarre; 
for example, one patient attempted suicide by hanging himself 
stark naked; another, a medical student, lay in a warm bath 
and opened the external jugular, median basilic and internal 
saphenous veins of both sides. Seclusiveness continues to show 
itself after the patient has been admitted into an institution. 
If the physician goes through his list of hebephreniacs after 
he has made his morning round, he finds he has missed many 
of those not confined to bed; they have been hiding. 


HEBEPHRENIA 333 


Hebephreniac depression differs from that of melancholia in 
that it is unaccompanied by the rigidity characteristic of that 
disorder and in being less persistent. Hebephreniacs momen- 
tarily cheer up from their depression, have a good look at their 


Fic. 59.—HEBEPHRENIAC SECLUSIVENESS., 


The patient is in the garden, locked out of the hospital; so she gets away 
from other patients into a corner as close as she can to a small outhouse 
(an uterine symbol). Symbolically she is saying, ‘‘ Let me get back into 
my mother’s womb.” 


surroundings, laugh in a childish senseless manner which is 
almost characteristic of the condition and, if they believe them- 
selves to be unobserved, run for a hundred yards or so along the 
garden path. 

At this stage a certain number of cases clear up and make for 


334 MIND AND ITS DISORDERS 


a partial or complete recovery; but, should the disease develop 
further, symptoms similar to those of dementia paranoides make 
their appearance. The patients think that people are making 
disparaging remarks about them or they believe themselves to 
be watched and followed by detectives or others. Then come 
hallucinations, especially of hearing; more or less systematized 
delusions follow in due course. A few of these patients subse- 
quently become exalted. 

In conduct they exhibit mannerisms and other symptoms 
characteristic of dementia precox; they are untidy in their 
dress, lounge about and talk to themselves. Their letters are 
over-punctuated, verbose and stilted; phrases are frequently 
repeated and words underlined. 

During the whole of this period there is progressive mental 
deterioration; the patient becomes more and more apathetic and 
loses all capacity for work. As deterioration proceeds, hallucina- 
tions sink into the background, delusions become forgotten and 
within a couple of years he is a confirmed dement. 

The restless cases differ but slightly from the depressed. The 
characteristic laughter is more in evidence and the patients are 
fairly contented and happy. They lounge about in comfortable 
attitudes, but never remain for many minutes together in the 
same place. They run the length of the ward to seek another 
seat. They are not missed by the physician on his round like the 
depressed patients, for they attract his attention by deliberately 
running away whenever he approaches them. 

Deterioration is more rapid in such cases. From the moment 
of entry into an institution they begin to put on weight and in a 
couple of months or so have become grossly fat. By the end of 
six months the dementia is profound; they are “ wet and dirty ”’ in 
their habits, totally incapable of looking after themselves, slovenly 
in dress and they carry food to their mouths with the fingers. 

Katatonia occurs rather more frequently in women than in 
men, and at a slightly earlier age than hebephrenia. It is that 
form of dementia preecox in which the motor symptoms, above 
described as catatonia and catalepsy, are the chief characteristics. 
Three forms have to be recognized: katatoniac depression, kata- 
toniac stupor and katatoniac excitement. 

Katatoniac depression is frequently mistaken in its early stages 
for melancholia. After a premonitory stage in which there is 
headache, loss of appetite, amenorrhcea and insomnia the patients 
become depressed, anxious and unable to follow their usual 
occupation. They are quiet and reserved and answer questions 


KATATONIA 335 


in monosyllables. Delusions develop rapidly; they accuse 
themselves falsely of past misdeeds, believe that people in the 
street insult them, either by actions or by word of mouth. 
They are called by disgusting names or dung is thrown at 
them. 

Examination of the patient reveals diminution of the super- — 
ficial and increase of the deep (tendon) reflexes, usually with 
loss of sensation. Rigidity is a striking characteristic but differs 
from the like symptom in melancholia in being uniformly dis- 
tributed, the muscular tension involving not only the trunk, 
shoulders and hips, but also the hands, feet and, in some cases, 
the face (Snautz-krampf). 

Negativism is shown by the patient’s refusal to speak (mutism) 
and by his resistance to all kinds of interference. He refuses to 
take food and has to be tube-fed, a procedure which frequently 
induces some verbigerative form of speech; but apart from any 
such interference verbigeration occurs from time to time, often 
accompanied by mannerisms. 

Katatoniac depression is the classical form of katatonia 
described by Kahlbaum in 1872 and it is probably the most 
favourable form of dementia praecox, some patients making an 
apparently complete recovery, even after the disorder has lasted 
for years. One of the author’s patients who was tube-fed for 
nearly twelve months at the beginning of her illness, became 
sufficiently manageable to return to her own home. There she 
took no real interest in her surroundings. If given a dustpan and 
broom, she would sweep the same patch of carpet for hours 
together and it was impossible to maintain a rational conversa- 
tion with her for any length of time. At the end of six years 
more or less favourable reports began to be received and eight 
years after she came under observation she made a complete 
recovery, so far as the author was able to ascertain by the most 
careful examination. Nevertheless the outlook for at least 75 per 
cent. of these patients is a profound and progressive dementia. 

Katatoniac stupor is occasionally preceded by a period of 
depression; usually it starts de novo. After the customary pre- 
monitory symptoms the patients become quiet and reserved and 
gradually pass into a condition of negativism. During the early 
stages there is peripheral analgesia (vide p. 117) which varies in 
extent from day to day. There is good perception and hallu- 
cinations are unusual, but they appear in a fair proportion of the 
cases. The patients are neither depressed nor excited; they are 
apathetic. Some, however, display a certain interest in their 


336 MIND AND ITS DISORDERS 


condition. For example, I have seen a patient take a surrep- 
titious glance at her hands after their atavistic nature had been 
demonstrated to a class of students. During the demonstration 
the patient’s negativism prevented her from evincing interest 
in the matter and even induced her to resist examination. | 

If it is permissible to say that one form is more characteristic 
of a disease than another, then it may be said of katatoniac 
stupor that it is the most characteristic variety of dementia 
preecox. It isin katatoniac stupor that atavistic signs and other 
stigmata are most frequently encountered; it is in this form of 


Fic. 60.—DEMENTIA PR#COX GROUP. 


dementia precox that mannerisms, negativism, stereotypy, ver- 
bigeration and automatic obedience (echopraxia and echolalia) 
may be best studied. 

The disorder has received the appellation “ stupor ”’ on account 
of the immobility and mutism of the patients. They sit in a 
lounging posture with their hands in their laps or stand apa- 
thetically about corners of the ward. They cannot be induced to 
speak (mutism) or at most they will answer questions in mono- 
syllables or ask for their discharge in as few words as possible. It 
must, however, be recognized that these patients are not cases of 
truestupor. They know all that is going on around them and their 
mutism and immobility are forms of negativism, not of paralysis... 


KATATONIA 337 


In many cases the limbs will remain in any attitude in which 
they are placed (flexibilitas cerea) so that a typical patient might 
serve as an excellent lay figure for an artist, were it not that his 
negativism would cause him to move away. 

Some are restless and wander up and down, in circles, spiral- 
wise or like a caged animal. Any obstruction to these move- 
ments is either eluded or forcibly resisted. 

As in anergic stupor, some of these patients exhibit oedema of 
the hands, feet and face, and the extremities are liable to be 
abnormally cold and cyanosed. 

Katatoniac excitement is usually preceded by one or other, or 
-by both of the above varieties of katatonia. At first sight it bears 
a superficial resemblance to acute mania, but on closer examina- 
tion is found to differ from that state in many particulars. 

There is usually some diminution of sensation in the hands. 
Perception is normal, even in the most excited cases of kata- 
‘tonia. The patients know their whereabouts and are commonly 
able to give the date correctly. They recognize and know by name 
the doctors and nurses. Memory for recent events is unimpaired. 

It is, however, frequently very difficult to ascertain all these 
facts about any given case on account of the patient’s inaccessi- 
bility. His answers to questions are absolutely irrelevant; 
whereas in acute mania the patient can usually be induced to 
pull himself together momentarily to give a rational answer. 

The conduct, too, of these patients differs from that of acute 
maniacs in that they do not display excessive large-joint move- 
ment. They clench their fists, rotate their forearms, pick their 
bedding to pieces and perhaps throw it away. Nor is there the 
same continuity of motor excitement; the movements of kata- 
toniacs are sudden, impulsive, violent and reckless. They are 
wantonly destructive; they tear clothing, smash windows and 
articles of furniture, not in anger or for fun, but merely to do 
that which will be objectionable; their destructiveness is a form 
of negativism. 

Negativism is displayed in other ways, such as refusal of food, 
refusal to shake hands, averting the head and, in general, doing 
the opposite of what is required. 

The patients are “‘affected”’ in their behaviour; they make 
grimaces, perform absurd antics and show signs of stereotypy 
and catalepsy. They are dirty in their habits, expose themselves 
indecently, adopt lascivious attitudes, apparently to annoy 
others, and smear the walls of their rooms with saliva, urine 


and feces. 
ie 


338 MIND AND ITS DISORDERS 


Such behaviour is sufficient evidence of deficiency of emotional 
tone and moral sentiment, even if further signs were wanting; 
but they are not. These patients feel neither joy nor sorrow, 
fear nor anger, anticipation nor satisfaction; and the meaningless 


imbecile smile, which is too unfrequently seen, is accompanied ~ 


by no emotional feeling. 

The speech is confused and more incoherent than in any case 
of acute mania. It consists of disconnected words and phrases, 
which are frequently repeated in the course of a single dia- 
tribe (verbigeration) and the language is abusive and obscene 
(coprolalia). 

From the point of view of prognosis this is the most un- 
favourable variety of katatonia. In the author’s experience it 
is rare. 

Dementia paranoides is a form of dementia przcox in which 
hallucinations and delusions, especially of hearing and of perse- 
cution, play the most important réle. The disorder is rather 
more frequent in women than in men. Sixty per cent. of the 
cases occur after the twenty-fifth year. 

This variety is characterized by delusions of persecution and 
of grandeur, which are constantly changing and associated with 
mannerisms and other signs of dementia precox and at times with 
mild states of excitement. The disorder may be preceded by 
states of depression and stupor. Dementia supervenes within 
two years, sometimes within six months, without remission. 

Kraepelin distinguishes two varieties: 

Dementia paranoides mitis, in which delusions develop as 
above described and simple hallucinations dominate the subse- 
quent clinical picture without causing profound disintegration 
of the personality, and 

Dementia paranoides gravis, a disorder of middle and later 
life, which begins in the same way but leads later to a character- 
istic dementia with emotional apathy and abnormal conduct. 

Sensation is unimpaired and perception is good. Hallucina- 
tions of hearing rapidly develop after a short incubation period 
of shyness, seclusiveness and suspicion. The import of these 
hallucinations is constantly changing and they form the basis of 
correspondingly variable delusions. The same patient hears 
mocking voices, proposals of marriage, invitations to leave the 
asylum, insults, statements that somebody is waiting in the en- 
trance porch for him, that poison is being secretly injected into 
him, that his clothes have been stolen and are being sold at an 
auction. He hears that he has obtained a title or some other 


DEMENTIA PARANOIDES 339 


distinction and suspects the attendants of attempting to appro- 
priate it to themselves. In some cases the voices are referred to 
telephones supposed to be in the wall and most absurd messages 
are received over the wires; one patient, for instance, heard the 
Austrian Emperor inviting him to drink paraldehyde with him. 

Hallucinations and illusions of vision sometimes occur; usually 
they take the form of faces and occasionally absurd visions are 
seen. One patient, on entering the bathroom, saw the bath 
suddenly stand up on end and lie down again. Hallucinations 
of smell are not uncommon; they give rise to the notion that 
poisonous vapours are instilled into the room. Similarly 
gustatory hallucinations induce the idea that the mouth is filled 
with objectionable matter. 

During this stage patients become emotionally excited and 
restless, in sympathy with the import of their hallucinations. 

As the disease progresses hallucinations become less frequent 
and delusions tend to be more expansive and more absurd. The 
patients believe themselves to be capable of speaking hundreds 
of languages, seeing people’s thoughts, creating worlds and 
emitting light. The delusions change many times in the course 
of an hour; but they are accepted and expressed without any 
corresponding emotional feeling. 

The patients grow incapable of mental work or continued 
application to any form of physical labour and dementia becomes 
confirmed in spite of comparatively good perception, orientation 
and memory. 

In his latest edition Kraepelin has multiplied his divisions of 
dementia precox by recognizing depressed, excited, circular 
and other forms as separate varieties; but these are all included 
in the above description and classification, which appear to the 
present writer to be more practically useful. 

Course and Prognosis.—In the majority of cases, dementia 
preecox proves to be a progressive disease leading to profound 
dementia. Ina few cases the progress of the disorder is arrested 
and the patient remains in a condition of partial dementia with 
poverty of character, deficiency of judgment and reasoning power, 
psychical apathy, loss of moral and, in general, limitation of the 
mental horizon. There is failure of ambition and energy so 
that he is satisfied to lead an idle life and become a parasite 
on his friends and relations. University graduates are content 
with manual labour on a farm; patients who have started on a 
lower grade of intelligence become the victims of evil companion- 
ship, the dupes of designing persons and perhaps take to drink. 


340 MIND AND ITS DISORDERS 


Recovery, apparently complete, takes place in a very small pro- 
portion of cases. Lastly, there is an intermittent form of the 
disease, in which the patient makes a fairly good recovery, then 
relapses several times before dementia is sufficiently pronounced 
for him to require permanent care inan asylum. In some cases 
of this kind remission and intermission take place at short 
intervals of a fortnight or a month. The intermissions are — 
occasionally associated with menstruation. These cases are 
sometimes erroneously regarded as maniacal-depressives. 

Dementia preecox appearing for the first time after forty years 
of age is incurable. 

The severity of the symptoms is a very fallacious guide to 
prognosis; some patients, who show but slight symptoms in the 
early stage of this disease, sink steadily into dementia. 

Prognosis differs slightly in the several varieties of dementia 
precox. Kraepelin gives the following results of his statistical 
investigations: 

Of hebephreniacs 75 per cent. sink into profound dementia, 
17 per cent. are but partially demented so that under super- 
vision they are capable of a certain amount of useful work and 
8 per cent. apparently recover. 

Of katatoniacs 60 per cent. reach extreme dementia, 27 per 
cent. are partially demented but sufficiently improved to justify 
their being allowed to return home and 13 per cent. recover 
at least temporarily. 

In dementia paranoides recovery never takes place. Short 
remissions occur infrequently, but the ultimate outlook is in- 
variably hopeless. 

Morbid Anatomy and Pathology.—The convolutional pattern 
of the cortex is often abnormal, but otherwise the brain exhibits 
no naked-eye changes. 

With regard to microscopical appearances, Alzheimer, Sir 
Frederick Mott and others have described areas of gliosis or glio- 
matosis in the deeper layers of the cortex and Turner described 
immature nerve-cells, one of which is figured in the accompanying 
photomicrograph. In advanced cases there is widespread destruc- 
tion of nerve-cells throughout the cortex, many being shrunken, 
distorted and eroded at the margin. The nuclei also are shrunken 
and dislocated and they stain deeply with methylene blue. 

Several investigators, in fact all who have studied the matter, 
have reported that the Abderhalden reaction in dementia praecox 
is positive to the sex glands in at least half the cases, indicating 
that destruction of these glands is an essential feature of the 


PATHOLOGY OF DEMENTIA PR#COX 341 


disease. It is not likely to prove the cause, because dementia 
preecox is related by heredity to mental disorder, not to disease 
of the ovaries or testes. Sir Frederick Mott has confirmed the 
Abderhalden results by making a direct examination of the testes 
post mortem in cases of dementia precox, and he has found, 
both macroscopically and microscopically, regressive atrophic 
changes of an extraordinary character in most of his cases. 
The late Dr. Laura Forster, also working in his laboratory, found 
regressive degenerative changes in the ovaries of many of these 
patients; but also in those from other forms of mental diseases. 

Dr. Noland, D. C. Lewis and others have made the observation 
that the weight of heart in dementia precox is disproportionately 
small, also that the aorta and larger arteries are of smaller lumen 
than normal, and that their coats are thin. In seeking an explana- 
tion for these phenomena he naturally turned to the endocrine 
organs, and he found histopathological changes to be present 
invariably in the thyroid, adrenals, and gonads (aplasias, 
atrophies, scleroses and patchy hyperplasias). 

The abnormal arrangements of the convolutions and the exist- 
ence of immature nerve-cells both suggest an inherent structural 
deficiency of the nervous system and there is an analogy between 
these features and the atavistic stigmata described in the earlier 
part of this chapter. 

Jung, who has made a special study of the psychology of this 
disorder, regards it as an “‘introversion’’; by which he means 
that the patients, finding a difficulty in fitting themselves into 
the world of reality, retire from it and live in a world of their own 
creation. This notion is not inconsistent with the view that 
they have reverted, both in bodily conformation and mental 
characteristics, to a former era in the history of the race. Even 
many of the symptoms (dirty habits, imitativeness, crawling on 
all fours etc.) might be regarded as atavistic; but how are we to 
explain the physical degeneration of the brain and other organs ? 
In retiring from the world of reality and creating a world of 
their own they escape many problems and mental conflicts but 
meet many others in the process which require disentangling 
and solving. As already stated, Jung is of the opinion that 
this process is to be held responsible for the formation of toxins 
which induce tissue degeneration. 

For the present, therefore, we must adopt an agnostic position. 
We do not even know whether dementia pracox is primarily 
an organic or psychogenic disease. 

Treatment.—Since the pathology of this disease is still some- 


-342 MIND AND ITS DISORDERS 


what obscure the treatment must, for the present, be merely 
symptomatic. When the patient first comes under observation 
he is almost invariably found to be suffering from malnutrition 
and insomnia. Accordingly our first efforts are directed to in- 
creasing his weight and procuring sleep. These results are to be 
obtained in the same manner as in mania and melancholia. The 
patient requires plenty of rest and the treatment must accord- 
ingly be carried out in bed. The duration of bed-treatment 
varies with the severity of the case. Mild cases of hebephrenia 
and dementia paranoides may be allowed to get up for a few 
hours each day after the lapse of a fortnight or three weeks. 
Some severe cases of katatonia require rest in bed for six, nine 
or even twelve months before a satisiactory state of nutrition is 
achieved. 

On account of the low blood-pressure in this disease Rae 
Gibson advocates the administration of digitalis and strychnine 
and Ishida recommends repeated injections of normal saline 
solution (about 500 c.c. at a time). Both of these observers 
record encouraging results. 

It is possible that the patient may be ameliorated or even 
cured in some cases by unearthing repressed complexes by 
association experiments and other methods of psycho-analysis, 
but the results have not up to the present been encouraging. 

Unlike all other neurotics and psychotics, patients suffering 
from dementia preecox do best in their own homes, at least 
during the earlier stages. Degeneration appears to progress 
more rapidly after they are sent to an asylum. It makes no 
difference to the ultimate result; there comes a time when an 
asylum is the only suitable place for such a patient, in his own 
interests as well as those of the community. 

Occupation is beneficial to patients suffering from dementia 
paranoides.and mild forms of hebephrenia. Life in a colony for 
the insane is well adapted to such patients; the time comes when 
ordinary home life does not suit them. They are easily irritated 
by people who do not understand them and, on the other hand, 
they are usually very irritating to other people. 

Some cases in America are said to have been improved after 
excision of the thyroid gland. Further evidence must be forth- 
coming before such a measure is likely to be attempted in this 
country. It is difficult to see the rationale of the proceeding 
and those reports which the author has seen are very uncon- 
vincing. Similarly, he does not know why calcium lactate is 
sometimes given as a routine medicine. 


FIG. 61:—bWo BETZ. CELLS: 


The one to the right shows a normal arrangement of its 
Nissl bodies, and the nucleus is in a normal position. Inthe 
upper part of the cell is a small collection of pigment. Note 
that the axon and the eminence from which it springs are 
devoid of Nissl bodies. . 

The other cell issomewhat swollen, hasa displaced nucleus, 
and the Nissl bodies are small dust-like particles. This re- 
presents a defectively developed or immature form of cell, 
found in idiocy, imbecility, epilepsy and dementia pracox. 
(x 400.) [Negative kindly lent by Dr. John Turner of Brent- 
wood Asylum.] 


To face p. 340 


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Ole Vad Sd UO 
PARAPHRENIA. 


PARAPHRENIA is the name applied by Kraepelin to a group of 
delusional cases formerly classed under dementia paranoides, 
or sometimes paranoia, but now brought together under a 
separate heading for several clinical reasons. 

The average age of incidence of paraphrenia is later than that 
of dementia paranoides; it is usually during the fourth decade, 
but in a few cases may occur as early as twenty-five or as late as 
fifty or more years of age. Hallucinations develop much later 
in the course of this disease than in that of dementia paranoides, 
there is not the same destruction of the personality to justify the 
appellation ‘‘ dementia ”’ and there are no catatonic or cataleptic 
symptoms. The disorder occupies a place midway between 
dementia precox and paranoia. It differs from the latter in 
that hallucinations invariably occur sooner or later and the 
delusions tend to be of a rather more bizarre character. 

Etiology. Except for the age incidence the causative factors 
of this malady have not been definitely established, but they 
are practically identical with those of paranoia. ‘Indeed the case 
of Dr. Schreber, whose autobiography was analyzed by Freud, 
really belongs here rather than to true paranoia. About 60 per 
cent. of the patients are men. 

Symptoms.—There is no disturbance of sensation and, apart 
from the hallucinations, perception is normal. Orientation is 
good, the patients recognize people and things quite correctly 
and their estimation of time is usually unimpaired; but I have 
known patients of this class who would insist that the generally 
accepted date was wrong by some days, weeks, months or years. 

There is no disorder of memory and, unlike dementia preecox, 
emotional reaction is normal. 

Similarly the behaviour may be regarded as normal but for the 
influence of delusions. The capacity for useful work is doubtless 
diminished in the later stages of the disease, but entirely on 
account of delusional preoccupation—the attention of patients 
being directed more and more from their usual pursuits to. 

343 


344 MIND AND ITS DISORDERS 


matters bearing on their phantasies. Insomnia is a frequent 
complaint. 

Paraphrenia is usually divisible into four well-marked stages. 

The first is the period of “‘ false interpretation ’’. The patient, 
whose normal mental attitude is one of suspicion, grows more 
suspicious and distrustful; he sees hidden meanings in trivial 
incidents. If people do not notice him as he goes to business, 
it is because they wish to avoid him; if they look at him, it is 
because they are detectives and he is under the surveillance of 
the police. One man coughs to draw attention to the patient, 
another blows his nose in order to conceal a smile with his hand- 
kerchief and a boy whistles a mocking tune as he passes. In the 
newspapers there are hidden references to his past life. One 
patient detected obscure indications that the letter H and the 
figure 8 had cabalistic significance for the Jesuits and Freemasons, 
not only in modern literature, but also in the classics, and 
thought that mankind in general, and himself in particular, were 
being duped by concealment of the importance of these signs. 

At this stage he may become depressed and despondent and 
accuse himself falsely of having lived a life of sin. Other patients 
complain to the police that they are being followed or persecuted 
by some unknown person or they take to travel to escape their 
enemies. Others again, of a more aggressive disposition, become 
violent and strike passers-by whom they suppose to have in- 
sulted them. 

The second stage, which usually occurs some years later, is 
characterized by the development of hallucinations of hearing, 
which reinforce any previous ideas of persecution and help to 
determine the character of the subsequent delusional state. 
The profound impression created by these hallucinations cannot 
be over-estimated. At first they may take the form of an 
unintelligible babel of voices; later, isolated words are heard, 
some being yet unintelligible, such as “ thiefist’’, ‘‘ death- 
swivel’’, then ‘‘ murderer’’, ‘‘sodomite’’ etc. Then short 
sentences are heard in which remarks (often untrue) are made 
about the patient’s doings. 

In some cases two voices or sets of voices are distinguished, 
one accusing or annoying the patient, the other defending him, 
accusations and insults being heard with one ear and friendly 
remarks with the other. 

The idea of friendliness or protection is welcomed by some 
patients at this stage to such an extent that it displaces the 
ideas of persecution and becomes the main element in the delu-: 


PARAPHRENIA 345 


sional state. Important persons may be fixed upon as their 
guardian angel—the Lord Mayor, the King, the Pope, or even 
the Kaiser. 

Verbal psychomotor hallucinations are experienced by some 
patients and give rise to the delusion that people are able to read 
their thoughts. Olfactory and gustatory hallucinations, which 
are not quite so common, induce corresponding delusions. 

Hallucinations of the cutaneous senses occur with some 
frequency and are often referred to by some neologism of the 
patient; he complains that he is “ spreethed’’, “ torched ”’ or 
‘“ cheefened ”’ at night or annoyed by “‘ the electric pin ”’. 

Genital hallucinations, when they occur, induce the delusion 
in women that they are pregnant or that they have been violated ; 
and in men that they have been castrated, or that painful 
erections have been caused by some base means. 

Visual hallucinations are rare and, when they appear, the 
patients at first seem to realize their true nature, at least to 
such an extent that the course of the disease is unaffected by 
their occurrence. 

The persistence of these hallucinations and ideas of persecu- 
tion gradually leads the patient to believe that he is the victim of 
a systematic conspiracy to annoy him, or of a band of persecu- 
tors, perhaps under the floor. Sometimes he fixes upon an 
individual of his acquaintance as the cause of all his trouble. It 
is in such cases as these that murder becomes an incident in the 
disease and the case acquires medico-legal importance. 

Very rarely remission may occur and the patient make an 
apparent recovery during the first stage of the disease; but if 
the second stage becomes well established, or the patient enters 
upon the third about to be described, the prognosis is absolutely 
hopeless. 

The third stage is characterized by the development of delu- 
sions of grandeur which gradually efface those of persecution. 
Not all the cases, however, develop grandiose ideas. Authors 
differ as to their frequency, but there appears to be little doubt 
that at least half of these patients reach a stage of grandeur. It 
may arise in one or more of three different ways: 

I. Subconsciously the patient seeks a reason for his continued 
persecution and comes to the conclusion that he must be some- 
body of importance. 

2. He hears himself referred to in hallucination as some great 
personage. This is really “ putting the cart before the horse ’’; 
because, after all, the hallucination is itself a creation of the 


346 MIND AND ITS DISORDERS 


patient’s own mind, the fulfilment of one of his unconscious 
wishes. 

3. An accidental occurrence, a misinterpreted conversation or 
a chance resemblance observed by the patient between himself 
and some magnate portrayed in the illustrated papers directs 
his attention to the notion that he is an important individual. 

One of the author’s patients observed a resemblance (a very 
remote one) between himself and the Duke of Saxe-Coburg. 
Thenceforward he believed himself to be of royal descent. 
Another heard in hallucination the words “ His Majesty’. 
From that moment he regarded himself as King Edward VII. 

We must not allow ourselves to be misled into supposing that 
this classification of the modes of origin of expansive delusions 
offers any explanation of their occurrence. The main fact that 
we have to realize is that it is in the nature of this disorder that 
a stage of grandeur should develop in most cases, for we have 
seen that the hallucinations and delusions tend to become 
expansive even in dementia paranoides. The explanation of 
this sequence of events is not quite clear; it would be interesting 
to know if a sane individual, subjected to real persecution similar 
to that from which these patients believe themselves to suffer, 
would ultimately tend to become exalted. 

When ideas of grandeur first begin to develop it is usually 
a difficult matter to elicit them even by the most searching 
examination. The patient remains reticent about them for 
months; but when they are well established he is prepared to 
give expression to them and even to reiterate them with untiring 
monotony. It is sometimes possible to discern the incidence of 
expansive delusions by a change in the patient’s behaviour. He 
talks with a more self-confident air than hitherto, disdains his 
relatives as being unworthy of him, carries himself with un- 
mistakable hauteur, and gives stilted hints of his greatness. 

Varieties.—Kraepelin describes four varieties of the disease. 
He expresses the doubt that one of these (paraphrenia phan- 
tastica) may really belong to dementia precox (paranoides) ; 
but I know quite well the type of patient to which he refers 
and can justify his opinion that these are not cases of dementia 
preecox, but of paraphrenia. I add a fifth type to include Dr. 
Steen’s “‘ chronic hallucinatory psychosis ”’. 

Paraphrenia Systematica includes the majority of the patients. 
It conforms in a general way to Magnan’s “ Délire chronique 
ad évolution systematique’’, but does not lead to dementia. As 
detailed above, delusions of persecution develop slowly and 


VARIETIES OF PARAPHRENIA B47 


systematically as in paranoia; but they are accompanied by 
hallucinations. Delusions of grandeur may appear ultimately 
and sometimes they are present from the beginning. 

Paraphrenia Expansiva occurs almost exclusively in females. 
Delusions of persecution and grandeur occur, but the latter 
preponderate and the patients are in a chronic state of mild 
excitement. Visual hallucinations predominate and, in about 
half the cases, the substance of the megalomania is erotic. 

Paraphrenia Confabulans is a rare variety which develops 
rather rapidly. In my experience it usually occurs later in life 
than the others; but—as I write—I have just seen a patient of 
this kind aged 29. The chief characteristic is illusion of memory 
with an extraordinary amount of confabulation. It is common 
for the patients to claim noble birth, this being frequently based 
on memories of early childhood. The above patient believes 
herself to be Christ. 

Paraphrenia Phantastica is less systematized than the above 
varieties. Cutaneous hallucinations play an important réle and 
take the form of bodily annoyance. Delusions of persecution 
consequently arise, but these are more changeable than in 
other forms of the disease. Neologism is common in this 
type. 

Paraphrenia ab hallucinatione.— Dr. Steen has drawn atten- 
tion to a class of case in which the psychosis manifests itself 
by hallucinations from the very beginning. At first the 
patients apprehend the true nature of their hallucinations, but 
this insight is gradually lost and delusions develop appar- 
ently from them, the ultimate psychosis falling in line with 
one or other of the above-mentioned varieties. I have there- 
fore ventured to rename Dr. Steen’s ‘‘ chronic hallucinatory 
psychosis ’’ in such a way as to indicate where I place it in 
Kraepelin’s scheme of classification. Doubtless the cases might 
be included in one of the above four varieties of paraphrenia, but 
it is desirable to recognize the possibility that hallucinations 
may be the very first symptom. 

Course and Prognosis.—The prodromal stage of the disease is 
_sometimes much prolonged, so it may b2 as long as six years 
before a patient of this class is brought for medical advice. In 
the meantime he has been carrying on his usual work quite 
normally except that his associates have regarded him as peculiar 
on account of his suspicious nature, irritability or other 
symptoms. 

Paraphrenia is essentially a progressive disease and, whilc it 


348 MIND AND ITS DISORDERS 


does not tend to shorten life, the ultimate outlook must be 
regarded as hopeless. Paraphreniacs never recover. 

Diagnosis.—Enough has already been said to indicate the 
differences between this disease and dementia prcox or paranoia. 
The only other malady which is likely to present any difficulty 
in respect of differential diagnosis is chronic hallucinatory 
insanity of alcoholic origin described on p. 413. The psychical 
mechanisms of the two disorders are exactly the same; the only — 
difference is that, in alcoholic cases, the poison has induced such 
degeneration of the cortical neurons as to allow the homosexual 
complex to escape the repression; but only partially, so that 
the complex becomes manifested in symptomatic guise. 

Treatment.—Since paraphrenia is an incurable disease, treat- 
ment resolves itself into general management. 

This consists of making the patients as comfortable and happy 
as possible. In the long run this is almost invariably in asylum 
care, but I know one patient of this class who, although an 
asylum case for over a year at one time, has remained at large 
and earned a meagre livelihood for many years in spite of persis- 
tent symptoms. He has fought the battle of life with moderate 
success; but I think that he would have been happier if he had 
been secluded from the world all this time, as nearly all other 
paraphreniacs are. 

5 with paranoiacs, however, I like these patients to vee carry 

’ to the best of their ability in the outside world, if they can 


eae do so. 


CT DT nex Te 
EPILEPSY AND EPILEPTIC INSANITY. 


“EPILEPSY is a disease characterized by occasional, sudden, 
excessive, rapid local discharges of the cortical grey matter ’’; 
but the name should not be applied to patients suffering from 
the convulsions of alcoholism, plumbism, uremia, gross brain 
lesions or general paralysis. Similarly, the practitioner must 
not be too ready to jump to the conclusion that a patient 
is suffering from epilepsy merely because a convulsion has 
occurred; as sometimes happens episodically, for example, in 
cases of dementia preecox or the anxiety neurosis. The above 
definition, which owes its origin to Dr. Hughlings Jackson, 
requires but little explanation. That the discharges are sudden, 
excessive and rapid must be obvious to everybody who has 
witnessed an epileptic fit. The epithet “ occasional ’’ was intro- 
duced into the definition in order to exclude discharges which 
are not occasional, such as the “interrupted continuous ”’ dis- 
charges of chorea; and the epithet “local”’ is justified by the 
fact that, while the characters of an epileptic fit differ in different 
cases, they resemble one another in the same case. Each 
individual patient invariably experiences the same aura and 
invariably falls on the same spot of his body, e.g., the fore- 
head or, more rarely, the occiput. With those whose fits are 
ushered by a cry, the cry is invariably of the same character 
for each patient; and if the tongue is bitten, it is in exactly the 
same spot in each successive fit. Lastly, and this is the point 
which most concerns those who have to deal with mental disease, 
if the patient is liable to an attack of mental disturbance before 
or after each fit, the nature of the mental disturbance is the 
same in successive attacks. | 
Etiology.—By far the most common cause of epilepsy is 
hereditary predisposition. Kraepelin obtains a history of 
nervous disease in no less than 80 per cent. of his cases and 
of epilepsy in the parents in 25 per cent. Epileptics almost 
invariably have some stigmata of degeneration. Cranial and 
349 


350 MIND AND ITS DISORDERS 


facial asymmetries, deformities of the palate and ears, microph- 
thalmos, microcephaly and prognathism are among the most 
common malformations. 

Alcoholism in the parents is commonly believed to be one of 


the causes of epilepsy. Such a belief does not necessitate the — | 


acceptance of the doctrine of heredity of acquired characters, 
but rather that the inclination to intemperance is a sign of 
neurotic tendencies and that the parent’s abnormal behaviour 
during the childhood of the patient has had a profound evil 
influence on his personality. It is more certain that alcoholism 
in the patient may give rise to epileptic fits. 

_ Seventy-five per cent. of the cases begin before twenty years 
of age and 16 per cent. between twenty and thirty. Males and 
females are equally liable to the disease, except in later life, 
when the incidence is rather greater in males. 

A certain number of cases date’ from some head injury or are 
dependent upon a cerebral lesion of vascular or syphilitic origin. 
Under this heading are to be reckoned the epilepsies due to 
“ birth palsy ”’ 

Scarlet fever appears to be responsible for a few cases, the 
first fit occurring in the course of or immediately after an attack 
of this disease. Predisposition is probably the most potent 
factor in the causation of these cases and also of those which 
are ascribed to irritation arising from normal dentition, carious 
teeth or intestinal worms. 

Epileptic insanity rarely, if ever, develops before the epilepsy 
has been of long standing and patients often retain their full 
mental vigour although they have been subject to fits for many 
years. Julius Caesar, Mahomet, Peter the Great and Napoleon I. 
are the usual classical examples, but in all of these cases the fits 
appear to have been rather infrequent. 

The main factor which determines the incidence of epileptic 
insanity appears to be frequent recurrence, rather than severity 
of the convulsions; indeed, it has been pointed out by many 
authors that insanity is more liable to occur in patients who 
are subject to attacks of minor epilepsy than in those who suffer 
from major epilepsy only. It has been said that insanity is 
liable to develop soon when the epilepsy begins late in life, but 
I do not agree with this dictum. 

As will be seen later there is good ground for the belief that 
some sort of toxemia is directly responsible for the more striking 
manifestations of this disease; but psycho-analytic investiga- 
tions afford very strong evidence in favour of the view that the 


THE EPILEPTIC CHARACTER Bees 


primary factors of epilepsy are purely mental and that all 
the observed physical characteristics are secondary to these. 
Hitherto, in spite of the wealth of material for study and the 
devotion and many discoveries of countless eminent physicians 
and pathologists to its investigation, the ultimate cause of 
“idiopathic ”’ epilepsy has remained a hidden mystery. 

In recent years, however, much light has been thrown on 
the real nature of this disease by psycho-analytical studies of 
epileptics, especially by Pierce Clark in America and by Ferenczi 
and Maeder on the continent of Europe. To such superficial 
observers as we have all been in the past, the convulsion is the 
most striking and important feature of epilepsy, but the above 
psychologists have demonstrated that. the mental make-up of 
the patient in whom the convulsion occurs is of much greater 
fundamental importance. In other words, epileptic fits are only 
a part of the epileptic character. This statement is likewise 
applicable to some of the organic epilepsies, such as those of 
infantile hemiplegia and diplegia, alcoholism etc., the lesion 
merely permitting the epileptic character to assert itself. 

The Epileptic Character.—It is desirable to consider the mental 
characteristics of the chronic epileptic also because these may 
be of practical diagnostic significance, seeing that some hysterical 
and other convulsions are often indistinguishable from those of 
true epilepsy—to such an extent that I am in the habit of 
speaking of that condition as ‘“‘ psychogenetic epilepsy ”’ without 
losing sight of the fact that all epilepsy is really psychogenetic. 

Moreover, the study of the epileptic character demonstrates 
epilepsy to be essentially a mental disease—a fact which is liable 
to become minimized by or forgotten on account of the maze of 
important pathological findings, especially the changes in the 
composition of the blood. 

Apart from the tendency of true epilepsy gradually to reduce 
the intellectual capacity, even to apparently extreme dementia 
in many cases, the patients suffer from poverty of ideation and 
sluggish mentality similar to that of a child of four or five years 
of age. Indeed this mental infantilism is the keynote of all the 
mental characteristics of the epileptic. He has a small vocabu- 
lary and Jung reports that he finds that the word-reactions (vide 
Pp. 53) are like those of children or imbeciles. The patients are 
self-centred; they attach undue importance to their own activi- 
ties, however childish and unimportant these may be; they tend 
to forget matters of general interest and knowledge and to re- 
member only those of personal interest, they feel that their 


352 MIND AND ITS DISORDERS 


personality should be of as much interest to others and the 
discovery that it is not may lead to delusions of persecution ; 
there is often a certain amount of vanity exhibited in their dress— 
at any rate they are especially pleased with uniforms or decora- 
tions of various kinds; they pay unnecessary attention to their — 
bodily health, especially with regard to actions of the bowels 
and any slight discomfort about the anus—a small hemorrhoid 
is sure to claim plenty of attention. There is a rise of the egoistic 
sentiments and decline of the altruistic; epileptics try to get 
others into trouble and to obtain sympathy for themselves. 
Hence we find that it is in the epileptic ward that most of the 
charges of cruelty to patients have to be investigated; for 
example, a patient accuses an attendant of having struck him 
and exhibits a self-inflicted bruise to substantiate the charge. 
The conduct of the epileptic is peculiarly brutal and ferocious; 
if he is offended, he reacts with wholly disproportionate violence, 
and murder is one of his instincts. 

The remarkable degree of religiosity of the epileptic appears at 
first sight to be paradoxical to such a character as we have 
portrayed. Night and morning he reads his Bible, sings hymns 
for all to hear and, like the typical Pharisee, falls upon his knees 
in prayer at opportune and inopportune moments in public. 
This is probably the expression of an infantile desire for de- 
pendence on “ the father ’’, as Gallus has suggested. 

At adolescence the sexual instinct is uncontrolled and the 
patient takes to masturbation or commits other unnatural sexual 
offences. His instincts are criminal, a fact recognized by the 
prison authorities who make ample provision for epileptics in 
the form of padded rooms, etc., in all the larger prisons. More- 
over, the remarkable frequency of sexual offences as “ epileptic 
equivalents ’’ hereinafter described, suggests that the sexual 
instinct plays an important rdle in this disease. 

It is not difficult to discern an auto-erotic basis and narcis- 
sistic tendency in the epileptic character above outlined; but 
this is not all. During an “epileptic equivalent ’’ when the 
patient’s normal consciousness is in abeyance and his uncon- 
scious personality holds uncontrolled sway, he is liable to commit 
violent sexual aggressions which are usually of a perverse nature, 
such as exhibitionism, homosexual advances and so forth, 
although they are sometimes of a more normal character. Even 
apart from definite epileptic attacks these patients are apt to 
become sexually turbulent and violent in abnormal ways, the 
normal channels of outlet being insufficient to satisfy their 


THE EPILEPTIC CHARACTER 353 


libido. Such observations bring us back to the same conclusion 
—that the epileptic character is infantile, the sexual tendency 
being “ polymorph-perverse ’’, to use Freud’s expression, just 
as in the normal child. 

In most asylums, probably in all, the inmates of the epileptic 
ward are generally regarded as being potentially ‘“‘ dangerous ’’. 
Their instincts are criminal, but it must be admitted that a few 
of these patients are good-tempered when at their best and will 
assist the attendants in nursing the more troublesome patients. 
Even this feature is probably an infantile characteristic, for 
children like to identify themselves with their mother and to 
help her in something she is doing. At least those readers who 
are familiar with psycho-analysis will discern the possibility 
that to the unconscious mind of the patient the attendant may 
symbolize the mother. 

With very few exceptions, an epileptic can tell us nothing of 
his thoughts occurring in association with or during a full-blown 
convulsion; but, after an attack of petit mal, he can frequently 
give some account of his mentality. Such reports, as well as 
the dreams of epileptics, afford evidence that the purpose of 
the fit is of a twofold nature, viz., (1) To gratify sexual desire 
vid muscular and respiratory activities (orgasm), and (2) to 
retreat from the world of reality vid unconsciousness. This last 
is really the fulfilment of a wish to return to the prenatal state 
(metro-erotism of Pierce Clark); indeed a few epileptics after 
a fit have made the definite statement that they have been in 
their mother’s womb. He is not only infantile; he desires to 
be still more so. 

The mental infantilism of the epileptic is especially striking 
in the domain of sexuality. In females the menstruation is late 
and scanty, in males nocturnal emissions do not occur before 
eighteen or nineteen years of age and masturbation persists long 
after marriage. In later life the menopause occurs early, and 
in males there is a tendency to handle the genitalia without any 
attempt to provoke emission—just like a child. 

Should the mother pass out of the patient’s life, by death or 
otherwise, the transference to some surrogate, such as an elder 
sister or a nurse, occurs almost immediately. The patient is in 
constant search for mental shelter and, when he fails to find it, 
the accumulation of displeasure affects finds relief in a paroxysm, 
just as children react to unpleasant situations by kicking, 
screaming, stamping their feet and so forth. 

This infantile character antedates the occurrence of the first 

23 


354 MIND AND ITS DISORDERS 


epileptic fit and there is plenty of evidence to show that the 
emotional defect is due to psycho-sexual immaturity. Our 
conclusion from all these considerations is that the convulsion, 
about to be described, must be regarded as a secondary charac- _ 
teristic of the disease. | 3 

Dr. Scripture has demonstrated a curious physical phenomenon 
which is probably of psychical origin. His patients are directed 
to speak into an apparatus connected with a revolving drum on 
which are recorded the strength of the puffs emitted during 
vocalization. A line connecting the tops of the ordinates shows 
what he calls the ‘“‘melody plot’’. In a normal person the 
melody is a variable rise and fall, but in epilepsy the vowels run 
along in an even tone—“ plateau speech”’. Dr. Scripture 
ascribes this to the slowness and deliberateness of the epileptic. 
With practice it is possible to detect by direct observation this 
peculiarity of the epileptic voice. 

Preparoxysmal Stage.—When an insane epileptic is about to 
have a fit, an experienced attendant is usually able to detect 
a characteristic change in the patient’s conduct for a couple of 
days or so before the convulsion. He is restless and sleepless 
and his customary impulsiveness is exaggerated. He may 
become bad-tempered, gloomy and unable to follow his usual 
asylum occupation; he may be suspicious with delusions of per- 
secution or elated with delusions of grandeur or a true maniacal 
attack may be observed. 

Prodromal Stage.—This stage lasts from a few seconds to 
three minutes previous to the onset of the fit. It is in reality 
the beginning of the convulsion and is characterized by the 
appearance of the aura or warning, which is usually of a sensory 
nature. Warning does not come in all cases and is less common 
in insane than in sane epileptics. 

The epigastric aura, which consists of a feeling of oppression 
in the epigastrium, is the commonest. Most patients describe 
the sensation as travelling from the epigastrium up to the throat 
or into the head. Visual aure consist of hallucinatory appari- 
tions of people, either singly or in crowds, motionless or in move- 
ment. One patient used to see his own face, and address it: 
“Hallo, Fred! Is that you?’ Other patients experience 
visions of angels in the heavens or devils in hell. Frequently 
the hallucinations are less complex and appear as stars, sparks 
of fire or coloured lights. 

Auditory aure are less common and when they occur are 
usually crude, such as whistling or hissing in the ears, a crash 


EPILEPTIC AURE 555 


or a crack inside the head. Occasionally the aura consists of 
music or the ringing of church bells, the sexual significance of 
which is well known to psycho-analysts. Gustatory aure are 
not very common; they are usually unpleasant and accompanied 
by champing movements of the mouth. Olfactory aure are 
rather more common: when present, the patient experiences an 
unpleasant odour, usually of something burning, chemical fumes 
or decomposing animal matter. Hughlings Jackson pointed out 
that the olfactory aura is frequently accompanied by a “‘ dreamy ”’ 
state in which the patient has a sense of unreality of his sur- 
roundings. Occasionally the aura is motor, the patient running 
a short distance or turning round two or three times before 
falling unconscious in a fit. Other premonitions are a sense of 
fear, shivering, vomiting and an increased flow of saliva or sweat. 

A motor aura must obviously be regarded as the very begin- 
ning of the motor convulsion. Sensory aure give a clue in 
organic cases to the site of the discharging focus in the cortex. 
I have suggested that, in some cases, the physical basis of a 
premonitory hallucination may be the last part of the sensory 
cortex to be affected. For example, a patient suffering from 
the epigastric aura is on the road to unconsciousness, otherwise 
loss of sensation; and my suggestion is that, during the aura, 
loss of sensation has already begun in the limbs and that the 
epigastrium dominates consciousness because it is the last region 
to become anesthetic.* 

The Convulsion.—Simultaneously with the loss of conscious- 
ness the pulse becomes feeble and occasionally ceases altogether 
during the early part of the tonic stage, the face is bluish and 
the patient falls to the ground convulsed. The march of the 
spasm is so rapid that it is impossible to say which is the first 
muscle affected. To all appearance every muscle in the body 
contracts vigorously at the same moment. There is, to use 
Hughlings Jackson’s phrase, a “‘ clotted mass of movements ”’. 
That there 7s a definite order of spasm is obvious from the fact 
that different patients fall in different ways and each patient 
falls in the same way in successive fits, and Dr. Pierce Clark 
has been able in some cases to trace the attitude usually assumed 
during a fit to some situation of affective significance occurring 
during the patient’s childhood. 

As a rule the spasm is stronger on one side of the body than 


* Since writing the above Dr. Collins, formerly superintendent of the 
L.C.C, Epileptic Colony, has discovered peripheral anesthesia in an epileptic 
during a prolonged aura. 


356 MIND AND ITS DISORDERS 


on the other so that the head, eyes and mouth are drawn to 
one side. Should the contraction of the chest muscles happen 
to coincide with closure of the glottis, as it frequently does, a 
peculiar cry occurs as the patient falls. The elbows and wrists 
are slightly flexed and the hands clenched upon the thumbs; 
the lower limbs are commonly extended. The face becomes 
cyanosed owing to fixation of the chest. Urine is voided with 
such force as to suggest that the bladder muscles are involved 
in the spasm. This condition of affairs, which is known as the 
“tonic stage’”’, lasts about half a minute, at the end of which 
time the muscles momentarily relax, at first every few seconds, 
then more and more frequently. These relaxations become 
more and more prolonged and the intervening spasms shorter. 
In this, which is known as the “ clonic stage’”’, the convulsion 
appears as a series of jerks or spasms involving the whole body. 
At first the jerks are due to momentary synchronous relaxa- 
tions and later to momentary synchronous contractions of all the 
muscles of the body. It is usually in this stage, which lasts about 
one minute, that the tongue is bitten. An onlooker has there- 
fore sufficient time to obtain a tongue-depressor, spoon or similar 
implement to prevent this accident by sliding, for example, 
the handle of a spoon between the teeth on the first re- 
laxation and gently depressing the tongue until the convulsion 
is over. 

Some patients are liable to a series of five, ten or more up 
to 200 such fits without recovering consciousness in the intervals 
(status epilepticus). In this condition the temperature usually 
rises three or four degrees and the patient is reduced to a state 
of extreme exhaustion which may terminate fatally. 

During a convulsion all the superficial and tendon reflexes 
are in abeyance and cannot be obtained. After the fit the 
patient is exhausted and commonly sleeps for a quarter of an 
hour or so. This sleep is to be regarded as analogous to the local 
paralysis which occurs after a local fit arising from a lesion of 
the precentral gyrus. It is temporary universal paralysis. 
That this exhaustion is not only of the cerebral cortex, but also 
of lower nerve centres, is shown by the fact that in most cases 
the knee-jerk is diminished or absent. 

Defendorf reports that he made 1,088 observations on the 
state of the reflexes after epileptic fits. ‘“‘ The normal plantar 
reflex (flexion of the toes etc.) was present in both feet immedi- 
ately after clonus had ceased in 45 cases, and one hour later 
in 226 cases; the Babinski phenomenon (extension of toes with 


EPILEPTIC FITS Sy 


dorsiflexion of ankle) occurred in 103 cases directly after seizure, 
and in 112 cases one hour later. An extensor response was 
found in right or left foot in 99 and 53 cases respectively, and a 
flexor response in right or left foot in 99 and 211 cases respec- 
tively; while a mixed response, that is, extension in one foot 
and flexion in the other, occurred in 82 cases directly after a 
seizure, and in 147 cases one hour later. The plantar reflex 
was abolished in 660 cases immediately after the convulsion, and 
in 339 cases one hour later. The knee-jerks were active in 
396 cases, moderate in 137, and absent in 539 cases.”’ 

Epileptic attacks usually occur at intervals of two or three 
weeks, but their frequency varies enormously. One patient of 
mine, not insane, has had four convulsions in about twenty-five 
years. Another, also not insane, who had been subject to 
attacks about once a month, had no fit for ten years, during 
which time she had taken bromide regularly. She then ventured 
to leave off her bromide and at once had a fit. Brown-Séquard 
had a patient who had fits nightly for seventeen years and an 
average of twelve nightly for ten years. 

Many patients are liable to batches of fits, not status epilep- 
ticus; they have five or ten fits in the course of two or three 
days, go a couple of months without any attacks, then have 
another batch and so on. 

Not all epileptic attacks are as severe as the major attack 
above described. Sometimes muscular spasm occurs of such 
brief duration that it is unobserved by an onlooker, sometimes 
it lasts just long enough to be noticeable. In other cases the 
patient perhaps experiences an aura, momentarily loses con- 
sciousness and lets some object in his hand fall to the ground 
or even falls himself; but the attack appears to be unaccom- 
panied by muscular spasm. All these cases are classed as ‘‘ minor . 
epilepsy ’’ or petit mal. Hughlings Jackson pointed out that 
the physical basis of such attacks is in the functionally highest 
regions of the cortex which we now call “ association areas ’’ and 
that it is because the disorder in these cases is of the areas which 
constitute the physical basis of mind that minor epilepsy is 
especially associated with and liable to induce insanity; but we 
shall have to regard this as too materialistic a view of the disease 
if it is ultimately proved to be of purely mental origin—as seems 
probable. These minor attacks receive various names in popular 
parlance. Sometimes they are spoken of as “‘ faints’’, a term 
which will mislead only the most casual practitioner. Among 
asylum attendants they are usually called “‘ sensations ”’ 


358 MIND AND ITS DISORDERS 


Post-Epileptic Automatism.—It is especially after these minor 
fits that the condition known as post-epileptic automatism is 
likely to occur. The patient has a minor attack and imme- 
diately proceeds to perform some apparently purposive action of 
an irrelevant nature. For example, he may proceed to undress 
in the public street; this is quite common. I doubt whether 
anybody ever seriously accepted Sir William Gowers’s explana- — 
tion that it occurred on account of some vague sense of indis- 
position and the propriety of going to bed. We now recognize 
it to be the gratification of an unconscious desire to expose the 
body to public gaze. Many instances of automatism have been 
recorded. ‘‘ One man drove a waggon across London, and found 
himself six miles from the place where he was, as it seemed to him, 
a moment before’’ (Gowers). A bank clerk was sent on an errand 
to another bank, having entered which, he knocked a clerk off 
his stool, disarranged some papers but removed none and left 
the bank. Subsequently he remembered nothing of the incident 
except experiencing his usual epileptic aura on ascending the 
bank-steps. Then there is the classical case of the French 
judge who, after an attack of petit mal which occurred during 
a trial, micturated in the corner of his court before the public 
gaze, an incident of which he could subsequently recollect 
nothing. Occasionally, however, these post-epileptic states are 
remembered by the patient. A man, who worked in a ship- 
yard and had for some years been subject to attacks of “ giddi- 
ness ’’ with increasing frequency, went to the yard as usual 
one morning, worked for half an hour, then went and sat on a 
piece of timber. His comrades spoke to him but could get no 
answer, so he was taken to hospital. While there he would 
say nothing except the Lord’s Prayer, in reciting which he 
showed some difficulty of articulation. After a sojourn of a 
few days he was transferred to an asylum where he became 
almost immediately his normal self and was able to recount 
all that had happened to him in hospital, knew the names of 
the doctors there and related incidents which occurred during 
demonstrations of his case to the students. After a few days 
he relapsed and became an ordinary case of epileptic insanity. 
All such incidents would, or rather should, be subjected nowadays 
to analysis. 

Epileptic Equivalents.—States of automatism similar to the 
above sometimes occur independently of epileptic convulsion, 
major or minor. Such states are then regarded as substitutes 
for epileptic fits and are known as “ epileptic equivalents’. Of 


EPILEPTIC EQUIVALENTS 359 


these there are two varieties, the transient and the protracted. 
Both are almost always, but not invariably, characterized by 
subsequent loss of memory of the events which have taken 
place during the attack. 

The transient equivalent lasts from a few seconds to a few 
hours, rarely longer, and consists of an isolated impulsive act 
usually of a violent nature. One form of impulse is the “‘ epileptic 
flight ’’, in which the patient runs for ten or even twenty miles as 
if impelled by an irresistible force and perhaps strikes anybody 
who happens to be in his way. With some patients the flight 
takes place to the same spot in successive attacks. More 
commonly the impulse consists of a violent, occasionally mur- 
derous, attack. In other cases the criminal impulse is of a 
less violent nature, such as indecent exposure, arson or theft. 
Not infrequently these transient equivalents are immediately suc- 
ceeded by such post-epileptic phenomena as headache and sleep. 

Protracted equivalents last from a couple of days to two 
months. These are the attacks of true epileptic insanity most 
commonly seen in asylums. 

Under this heading we have to consider: 


Epileptic depression or ill-humour; 

Epileptic excitement; 

Epileptic confusion; . 
Epileptic delirium; 

Epileptic stupor (so-called epileptic catatonia) and 


, 


Epileptic automatism or ‘‘ double consciousness ”’. 


In epileptic depression the patient is dominated by a feeling 
that his surroundings are hostile. The condition resembles 
melancholia in which the patient regards his incapacity as 
being due to an increase of the resistance of his environment. 
He is irritable and querulous. He complains of everything, of 
the inferior quality of his food, of the antagonism of fellow- 
patients, of cruelty of the attendants and want of sympathy on 
the part of the doctor. He complains of headache, epigastric 
oppression, loss of appetite, bowel obstruction and a host of 
other physical ailments. He threatens or attempts suicide and 
requires the most careful supervision. 

Epileptic excitement is characterized by extreme intensity and 
severity, such as is rarely met in other forms of insanity. 

The aspect of the patient is forbidding; the face is pale or livid, 
the eyes staring, the facial expression either absent or indicative 
of readiness for attack. The movements are impulsive and 


360 MIND AND ITS DISORDERS 


violent; the patient makes mad rushes at the attendants or, if 
restrained, struggles blindly and furiously. This is the classical 
type of epileptic excitement which has received the name of 
‘epileptic furor’. The patient is either silent or garrulous and 
incoherent. | 

Nevertheless he is not entirely inaccessible; he can occasion- 
ally be induced to answer questions, but immediately relapses _ 
into incoherent babble. Criminal acts, such as suicide, homicide 
and crimes of a sexual nature, are liable to be committed in 
this condition. 

Not all cases of this epileptic excitement exhibit such 
passionate fury and violence. Some laugh convulsively, strip, 
turn somersaults, declaim or address irrational remarks to 
bystanders or to pictures on the wall. The disorder lasts from a 
few hours to a couple of days and is one of the states which have 
received the name of “ mania transitoria’’. As such nomen- 
clature is rather misleading, it is better that the term be allowed 
to drop. 

Epileptic confusion is a remarkable state in which the patient 
suffers from peripheral anesthesia, usually of extensive distribu- 
tion, imperception and disorientation accompanied by aimless 
wanderings and purposeless movements of the arms and legs. 
The patient cannot understand simple commands or appreciate 
the nature of his environment (imperception and disorientation). 
Occasionally a relevant answer can, by persistence, be obtained 
to simple questions. One patient in a London hospital told me 
that she knew she was somewhere near the sea because she could 
hear the sound of the waves; she really heard the noise of the 
traffic. This patient showed a certain amount of suggesti- 
bility. After demonstrating the case to a class of students I 
suggested that in about a week’s time she might possibly hear 
a crack in her head and suddenly recover. One week later, 
almost to the very minute, the patient heard a crack in her head 
and returned to her normal condition. The kudos I then 
obtained for remarkably clear insight into the patient’s malady 
was ill-deserved. The result was probably to be explained by 
the patient’s unsuspected suggestibility; it could hardly be a 
coincidence. 

The unique case of allocheiria of epileptic origin, mentioned on 
p- 123, occurred in a patient suffering from epileptic confusion 
of this nature. 

Epileptic Delirium.—The predominant characteristic of this 
form is the presence of terrifying hallucinations. The patients 


EPILEPTIC EQUIVALENTS 361 


see devils, animals, fire, blood or infernal machines destined to 
torture them. They believe themselves to be surrounded by 
enemies and they attack bystanders with intent to kill them. 
In some cases the hallucinations have a religious import; God, 
Christ and the angels appear to them in the heavens and perhaps 
speak to them. Such hallucinations may induce the patient to 
sing hymns or fall on his knees in prayer. These patients are 
completely disorientated and apparently suffer from impercep- 
tion, but it is difficult to test this point on account of their 
general dread of everything and their consequent motor ex- 
citement. 

In epileptic stupor there is extensive peripheral analgesia and, 
I believe, contraction of the visual fields. The pupils are dilated 
and react but feebly to light. The patients stand rigidly in 
one position, apparently oblivious of their surroundings; they 
assume catatoniac attitudes and flexibilitas cerea is not un- 
common. Usually they take no notice of external stimuli, but 
occasionally they resent interference and even strike passers-by 
impulsively. They are “ wet and dirty ” in their habits. 

Some take their food mechanically, others refuse all nourish- 
ment and require artificial feeding. Speech is absent or con- 
sists of irrelevant detached words and phrases uttered in a 
tone devoid of emotions; the patients do not respond to questions, 
probably in part because they do not understand them (im- 
perception). 

Epileptic Automatism.—In this state patients may commit 
extravagant, perhaps criminal, acts similar to those mentioned 
under the heading of post-epileptic automatism. Not infre- 
quently, however, they behave in an apparently normal and 
rational manner so that their condition is unsuspected. They 
perform unpremeditated complex actions of which they have 
no subsequent remembrance. The patient may forget his own 
name and even change his identity (double consciousness). The 
most striking instances are those in which a long journey is 
undertaken, the case being then reported in the lay press as a 
“ mysterious disappearance.” 

Legrand du Saulle has related the case of a merchant who, on 
recovering from his attack, found himself on the way to Bombay. 
Dr. W. S. Colman has told me of a guardsman, quartered in 
a London barracks, who suddenly heard a crack in his head and 
found himself in Newton Abbot having unintentionally absented 
himself without leave. Perhaps the most remarkable case of all 
is that of the Rev. Ansel Bourne, mentioned by Professor James. 


362 MIND AND ITS DISORDERS 


This patient, who was an itinerant preacher, disappeared on 
January 17, 1887, and did not recover until March 14 of the same 
year when he found himself keeping a confectioner’s shop under 
the name of A. J. Brown in Norristown, Pennsylvania, 200 miles 
away. During the whole of the attack nobody in Norristown 
ever suspected that there was anything wrong with the man. 

The duration of these attacks of so-called “‘ psychic epilepsy ”’ 
is from a few hours to a couple of months. Recovery may ~ 
be gradual or sudden, sometimes after prolonged sleep. There 
are cases of sudden recovery in which the patient at the moment 
of awakening hears a crack in his head. What this crack may 
be opens a wide field for speculation. The whole period during 
which the epileptic equivalent lasts is usually covered by com- 
plete, sometimes by partial, amnesia. Occasionally, on the other 
hand, the patient can remember everything that has occurred, 
as in the case of epileptic confusion above cited. Not all cases 
of double consciousness. are epileptic in origin; some are un- 
doubtedly hysterical. 

Narcolepsy, a condition of deep sleep lasting sixteen to twenty 
hours, sometimes occurs as an epileptic equivalent. It is followed 
in some instances by mild attacks of excitement. 

Post-Epileptic Insanity.—After an epileptic has had a convul- 
sion he is liable to attacks of mental disorder differing in no way 
from the epileptic equivalents above described. The question 
arises whether the so-called equivalents are not invariably pre- 
ceded by an attack of petit mal, so slight as to escape observation. 
I am convinced that this is so in a large number of the cases. 
Whether it is always so is a matter which, in all probability, can 
never be definitely settled. 

Epileptic Dementia.—In the course of time the repeated con- 
vulsions and attacks of true epileptic insanity begin to leave 
their apparently permanent mark upon the patient’s mentation 
and he becomes weak-minded. At first there is poverty of 
ideation, fallacious judgment, faulty memory, emotional in- 
stability and deficiency of moral tone. He is cruel to other 
patients and deceitful to doctors and attendants. He is irritable, 
vindictive, malicious and liable to unprovoked outbursts of 
anger. His look is uncertain, furtive and “ metallic ’’. 

His vocabulary becomes so impoverished that he has to express 
himself in circumlocutions. In narrating incidents he wanders 
off in long digressions and enters into unnecessary detail. On 
the other hand, he has difficulty in understanding the language 
of others (imperception). 


EPILEPTIC DEMENTIA 363 


When dementia becomes more pronounced the patient is com- 
pletely disorientated in time and place, imperception is complete 
and memory annihilated. He sits huddled up in a corner of the 
ward, is wet and dirty and leads a purely vegetative existence. 

The dementia may be as profound as that produced by general 
paralysis. Anesthesia of the hands is not uncommon in this 
condition. Nystagmus may occasionally be observed. 

The general disposition of epileptic dements is morose and 
suspicious and a few develop systematized delusions of persecu- 
tion. Hallucinations are rather uncommon at this stage. 

In spite of the apparent profundity of this dementia Dr. Pierce 
Clark has shown that it is not a true dementia, for he has suc- 
ceeded by his methods of treatment in alleviating it and even, 
in some such cases, completely curing the disease. 

Prognosis.—The earlier the age of incidence of epilepsy, the 
graver the prognosis. Children who develop epileptic fits before 
the age of seven are destined to become epileptic idiots incapable 
of education. This matter is dealt with in another part of the 
book. 

The more frequent the convulsions and the longer the duration 
of the disease, the smaller is the probability of permanent 
recovery and the greater the probability of subsequent insanity. 
According to Gowers, the prognosis is better when the attacks 
are limited to either the day or night than when they occur in 
both sleeping and waking states. 

Attacks of minor epilepsy are of grave significance because 
they are more difficult of arrest by treatment than major attacks 
and because minor attacks are more liable than major to become 
associated with epileptic insanity. 

The prognosis of epilepsy is unfavourable when the disease is 
induced by cerebral injury or a scar of some former cortical 
lesion. 

More important than any of the above factors in the prognosis 
of the disease is the treatment. This depends very largely upon 
whether the circumstances of the patient will allow of treatment 
being satisfactorily carried out. Ceteris paribus, if, during the 
early stages of the disease, the attacks are completely arrested 
by treatment for a period of two years, the chances of recovery 
are fairly good, recovery meaning freedom from attacks without 
treatment. These remarks apply equally to epileptic convul- 
sions, epileptic equivalents and other forms of epileptic insanity. 
Even in the early stages of epileptic dementia the beneficial effects 
of careful medicinal treatment (vide infra) may be observed. 


364 MIND AND ITS DISORDERS 


Morbid Anatomy and Pathology.—The most striking features 
in the morbid anatomy of an epileptic are teratological anomalies, 
not only cranial, facial and other asymmetries, but alterations in 
the modes of convolution of the brain. Further, the microscope 
reveals defectively developed and, according to some observers, 
hypertrophied nerve-cells in the cortex cerebri, as well as per- 
sistent subcortical nerve-cells, which occur normally in infancy 
and are also to be found in the brains of idiots. | 

Focal lesions of all parts of the cortex cerebri, basal ganglia and 
cerebellum are to be found in many cases of epilepsy and might 
‘reasonably be regarded as the primary cause of the disease; but in 
the majority of cases no such lesion is to be found. Sclerosis and 
atrophy of the cornu Ammonis occur in about 50 per cent. of the 
cases. This change, however, together with a general thickening 
of the meninges, infiltration of the perivascular spaces with 
leucocytes, increase of neuroglial cells and fibres, chromatolysis 
with vacuolation of the cortical nerve-cells, degeneration and dis- 
placement of nuclei and disappearance or shortening of the 
protoplasmic processes, is regarded by most pathologists as the 
result, not the cause, of the disease. 

The change described by Bevan Lewis as occurring mostly 1n 
the small cells of the second layer merits special consideration. 
Specimens stained by his “‘ fresh method ’”’ show an unstained 
bright refractile droplet of oil in the centre of the nucleus of these 
cells. In more advanced stages of degeneration the droplet is 
larger and replaces the nucleus. Later on the droplet is dis- 
charged and the cell, which still retains its contour, is left in a 
vacuolated condition. The change described is not peculiar to 
epilepsy, but Dr. Lewis claims that it is never so marked in 
other forms of insanity. 

Dr. John Turner (formerly of Brentwood Asylum) demonstrated 
in the cortical vessels the presence of blood-clots which stain green 
with Macallum’s phenyl-hydrazin reagent, showing that they 
contain phosphorus and are therefore of ante-mortem origin. 
Dr. Turner found this intravascular clotting in go per cent. of 
epileptic brains and in only 35 per cent. of control brains. He 
also points out that the blood platelets are excessively numerous 
in epileptics. 

Special attention has been paid by many investigators to 
the blood and urine of epileptics, with a view to discovering 
abnormal constituents. The general results of these investiga- 
tions are—(1) that, during an interval between attacks, the 
toxicities of the blood and urine are the same as in the case 


PATHOLOGY OF EPILEPSY 365 


of a healthy person; (2) that, before a series of fits, the 
toxicity of the urine is diminished and that of the blood in- 
creased; (3) that, during a series of fits or during an epileptic 
psychosis, the toxicity of the urine is still subnormal but tends 
to rise, while that of the blood, having been gradually rising 
for some time, now reaches its maximum and (4) that imme- 
diately after an attack the toxicity of the urine is increased, 
while that of the blood is diminished. Krainsky states that the 
chief abnormal constituent to be discovered in the blood is 
ammonium carbamate and he has succeeded in producing fits in 
animals by injecting defibrinated blood drawn from an epileptic 
during the course of a paroxysm. The obvious conclusion from 
these results per se is that the epileptic crises are entirely de- 
pendent on some toxin or toxins circulating in the blood-stream 
and that the fit fulfils the function, in some way or other, of 
transferring these toxins from the blood to the urine and of 
thus getting rid of them. Some authors contend that the bene- 
ficial effect of purgatives in diminishing the number of fits 
indicates that the gastro-intestinal canal is responsible for the 
manufacture of the toxins. The more probable explanation is 
that purgatives remove a source of peripheral irritation or 
gratify some unconscious desire. It is further stated that the 
urine of epileptics contains a smaller quantity of chlorides, phos- 
phates and nitrogenous products than that of normal individuals. 

Cotton, Corson White and Stedman discovered that the Abder- 
halden reaction of the blood of epileptics is always positive to 
adrenal tissue or rather, to be accurate, in every one of the 
69 cases in which they examined the reaction. 

A satisfactory explanation of the phenomena of epilepsy has 
therefore many clinical and pathological requirements to satisfy. 
It must take account of the facts that epilepsy is associated 
by heredity with other mental disorders, that it occurs in subjects 
with teratological anomalies of the cerebral cortex, that coma 
and other psychical phenomena are associated with the convul- 
sions, that the convulsions tend to recur, that each fit is an exact 
replica of previous fits in the same patient, that the patient is, 
at least in the earlier stages of the disease, perfectly well between 
the fits and that the occurrence of a fit usually tends, so to speak, 

o “clear the air’’. It commonly happens that a patient who has 
been for some days morose, irritable, querulous and suffering 
from occasional attacks of petit mal, suddenly has a severe con- 
vulsion, followed by sleep for half an hour or so, and is perfectly 
well until the preparoxysmal period of his next fit. The explana- 


366 MIND AND ITS DISORDERS 


tion which we seek must further take account of the occasional 
cessation of the pulse during the tonic stage of the convulsion and 
of such pathological findings as widespread degeneration of the 
cortex, intravascular clotting, sclerosis of the cornu Ammonis, 
the recurrent formation of toxins in the blood and their almost 
immediate elimination in the urine on the occurrence of a con- 
vulsion. We may leave out of consideration the cases in which | 
there is a definite irritative lesion of the brain. 

The problem which faces us is no easy one and the attempt 
to solve it has given rise to numerous theories as to the nature 
of epilepsy. The most important are: (1) The theory of cortical 
instability, (2) the vasomotor theory, (3) the toxin theory and 
(4) the theory of intravascular coagulation. 

The theory of cortical instability regards the epileptic as a 
person whose cortical neurons are so irritable that they occa- 
sionally burst into explosive activity from any trifling stimulus, 
peripheral or central, and give rise to a convulsion. This theory 
fails to explain the fact that an unstable cortex occasions 
epilepsy in one person and maniacal symptoms in another, but 
it is justified in that it recognizes the cerebral cortex to be the 
seat of the disorder, a fact which is at least minimized, if not 
totally ignored, by the supporters of the toxin theory. That the 
physical basis of epilepsy lies in the cortex cerebri is obvious 
from the study of the family histories of epileptics, from the 
cortical deformities and from the frequent association of mental 
disturbance with convulsions. The theory fails, however, by 
being incomplete. It throws no light on the nature of the 
changes in the blood and urine. 

The vasomotor theory takes account of the fact that convulsions 
are readily caused by the cortex being suddenly deprived of 
its normal vascular supply, either by cerebral embolism, ligature 
of the carotids or severe anemia from loss of blood. It further 
takes account of the occasional cessation of the pulse during the 
tonic stage of a fit, regarding such cessation as a vago-cardiac 
inhibition to check a continuous rise of blood-pressure induced 
by a widespread area of vaso-constriction. The view that such 
vaso-constriction occurs is supported by the observation that 
inhalation of amyl nitrite is sometimes successful in arresting 
an attack. One of my patients, who came to me with a history 
of one fit every day, and also suffered from Raynaud’s disease, 
had her fits entirely arrested by the administration of Io minims 
of the tincture of belladonna three times a day. According to 
the vasomotor theory, epileptic convulsions are caused either by 


THEORIES OF EPILEPSY 367 


the blood-supply to the cortex being cut off by a local vaso- 
constriction or by a sudden fall of blood-pressure following a 
rise caused by a widespread vaso-constriction. The Raynaud’s 
disease cases belong to the former class and the cases accom- 
panied by cessation of the pulse to the latter. 

According to the toxin theory, the fits are due to periodic ac- 
cumulation of fit-producing substances in the blood, especially 
ammonium carbamate. In accordance with this theory the 
direct effect of a convulsion is to cause the sudden elimination 
of toxins from the blood into the urine; otherwise there seems 
to be no reason why the convulsion should cease in so short a 
time. In this connection the reader will do well to recall the 
mental symptoms of toxemia, viz., hallucinations, anesthesia 
and mental confusion, all of which occur in association with 
epileptic fits. 

The theory of intravascular coagulation claims that the con- 
vulsions are directly due to cutting off the vascular supply to 
the cortex by the formation of blood-clots within the cortical 
vessels. That such coagulation occurs Dr. Turner has con- 
clusively demonstrated and he explains the fact that every 
fit occurring in any given patient is almost an exact replica of 
previous ones on the supposition that the character of the fit is 
determined by the position in the cortex of the imperfectly 
developed nerve-cells. Dr. Turner correlates the fact that the 
cornu Ammonis is especially liable to sclerosis and atrophy with 
the observation that the injection of clove oil into the jugular 
vein of a rabbit is especially apt to cause hemorrhages in the 
same region of the cerebrum. 

There seems to be no reason why we should discredit any of 
these theories. Our view of the pathogenesis of epilepsy will 
therefore be arrived at by an attempt to reconcile them some- 
what after this fashion. The disease occurs in persons with an 
imperfectly developed cortex cerebri. Owing to the accumula- 
tion of toxic products in the blood the vascular supply to the 
cortex is cut off by intravascular clotting and arterial spasm, 
these conditions giving rise to convulsion. The direct result of 
such convulsion is to eliminate the toxins from the blood and to 
cause the patient to return to his normal health. The instability 
of the cortex and the formation of toxins can hardly be a hap- 
hazard combination of circumstances. We therefore seem to 
be driven irresistibly to the conclusion that such toxins are 
manufactured within the nervous system itself. 

. But all this takes no account of the essential mental peculiari- 


368 MIND AND ITS DISORDERS 


ties of the epileptic, his affective immaturity, especially in the 
psycho-sexual sphere, the psychical meaning of the fits or their 
equivalents as libidinous outlets or strivings of the unconscious 
and the fact that they are as much the fulfilment of unconscious 
wishes as dreams are. What the exact relationship is between 
the mental and physical characteristics of the epileptic and 
which of these is responsible for the other are problems which 
still remain unanswered. 

For example, the reason why the Abderhalden reaction of the 
blood of epileptics is positive to adrenal tissue has not yet been 
explained. Perhaps it is to be correlated with Cannon’s dis- 
covery that every emotion is accompanied by an increase (or 
diminution) of the amount of adrenalin in the blood. This 
notion would, at any rate, not militate against the results of 
psycho-analytic investigation. 

The reader will rightly conclude from this section that the 
pathology of epilepsy is still obscure; but I am sure that he will 
be wise in laying due weight upon the mental aspects of this 
disease. 

Treatment.—When the physician is confronted with a case 
of epilepsy, it is his first duty to subject the patient to a most 
searching physical examination in order to ascertain whether 
there are, on the one hand, any peripheral sources of irritation, 
such as eye-strain, an uncompensated heart, indigestion and 
constipation or, on the other hand, any irritative lesions of the 
central nervous system which are capable of being localized. 
Eye-strain should be treated with suitable spectacles; heart 
disease, indigestion, constipation and similar disorders on general 
medical principles. Localized cerebral lesions should be first 
treated with hexamine and acid sodium phosphate in case they 
should be of infective or syphilitic origin. If such treatment 
fail to ameliorate the condition it may be desirable to resort to 
surgical measures. 

The patient should lead a regular life, keep early hours and 
live on a plain, nutritious, fattening diet, avoiding excess of 
nitrogenous food and totally abstaining from alcohol in any 
form. Under this régime it often happens that the fits entirely 
disappear. When I was resident at the National Hospital in 
Queen Square it was by no means an uncommon occurrence 
for an epileptic who had been treated as an out-patient on 
potassium bromide, to be admitted with a history of one fit every 
day in spite of treatment. On admission bromide was with- 
held until a fit had been seen and described; the simple life 


TREATMENT OF EPILEPSY 369 


proved to be so beneficial that not a single fit occurred during 
a month’s residence in hospital. 

Under this régime a record of the fits should be kept and their 
frequency noted; three fits a day, one a week or one a month 
as the case may be, unless the doctor is adopting some form of 
psychotherapy under colony conditions. The patient is now 
placed on bromide treatment, say 10 grains of sodium bromide 
night and morning and the frequency of the fits again noted. 
If they are entirely arrested the treatment can be continued for a 
few years and the dose then gradually reduced; if not, the dose 
should be increased and the frequency of the fits again noted. In 
this way the dose should be gradually increased up to the point 
beyond which no further diminution of the fits is accomplished. 
As a general rule it is not advisable to go beyond 45 grains of 
sodium bromide in the course of the day. A bromide rash may 
be avoided by the addition of 2 or 3 minims of liquor arsenicalis 
to each dose of medicine. It is usually desirable to add a mild 
saline aperient, say 15 to 20 grains of magnesium sulphate in each 
dose. A latter-day drug that is sometimes used instead of sodium 
bromide is luminal-sodium. In any but very small doses it has 
a stupefying or staggering effect on the patient; I therefore prefer 
to add quarter-grain doses (never more than half-a-grain) to the 
bromide mixture. Dialacetin is another drug to which the same 
remarks apply. 

If convulsions still persist various adjuvants may now be added 
to the mixture, borax being the first, beginning with doses 
of 5 grains and working up to Io or even 20 grains should it 
be successful in diminishing the frequency of the convulsions. 
The maximum dose of the drug is that beyond which no appre- 
ciable benefit is obtained. 

Now try lactate of zinc, tinctures of digitalis, belladonna 
and hyoscyamus, chloral hydrate and the liquor morphine 
bimeconatis, always keeping a record of the fits and noting the 
effect on the patient of the addition of any particular drug. 
If the drug proves beneficial it should be continued, if useless 
dropped. Above all things rule-of-thumb methods are to be 
avoided in the treatment of epilepsy; in no condition is it more 
important for the physician to bear in mind the rule that he 
should treat the patient and not the disease. 

Patients suffering from thirty or forty fits a day require more 
immediate and urgent treatment. In such cases the bromides 
are not very efficacious; chloral hydrate has proved a more 
useful drug. The best mode of administration is to give re- 

24 


370 MIND AND ITS DISORDERS 


peated doses in sufficient quantity, usually 10 to 15 grains 
three times a day, to keep the patient asleep, except for meals, 
for several days, perhaps for a fortnight in severe cases. The 
bromides may then by degrees be substituted for the chloral 
hydrate. | : 

Status epilepticus should be treated by giving a hypodermic 
injection of morphia, about 4 grain, and repeating it in three 
hours if necessary. A useful adjunct is an enema containing 
ro to 12 grains of chloral hydrate, after clearing the rectum as 
much as possible with a soap-and-water enema. Occasionally 
it is necessary to resort to chloroform inhalation. 

For those patients who have a definite warning before their 
fits the inhalation of amyl nitrite is sometimes successful in . 
preventing an actual convulsion. If the warning consists of 
a sensation in one of the limbs the convulsion may occasionally 
be warded off by giving a strong sensory stimulus to the limb 
by tying tightly round it a ligature such as a handkerchief. 

Epileptics should be under constant observation for the pre- 
vention of such accidents as falling into the fire, drowning in 
the bath or suffocation by the bedclothes when a fit occurs 
during sleep. The part of the body on which the patient usually 
falls should be covered with a pad. In some institutions pillows 
of reeds instead of flock are used for the purpose of minimizing 
the risk of suffocation, should a fit occur while the patient is 
in bed. 

All that has been said with regard to treatment applies equally 
to sane and insane epileptics. 

On the other hand, it must not be forgotten that one purpose of 
the epileptic convulsion is to eliminate toxins from the system 
and the question therefore arises whether it is not advisable 
to let some epileptics have their fits. Bromide undoubtedly 
does good in most cases, but it is not known in what way it acts— 
whether, for example, it neutralizes the toxins chemically or acts 
as a sexual sedative physiologically. We ought really to know 
this much before deciding whether it is desirable or not to give 
bromide at all. Indeed I have heard a very thoughtful and 
observant physician express a doubt whether bromide is of any 
use in the treatment of epilepsy. 

Every effort should be made to wean the patient from his 
infantile unconscious desire for dependence on his mother or 
father or their surrogates, such as the nurse or doctor. He 
should be removed from his own home and placed in a colony 
where, on the one hand, he is encouraged to lead his own life 


PSYCHOGENETIC EPILEPSY sya 


and, on the other, he is protected from irritations, as much as 
possible, which might induce him to regress into an infantile 
attitude of dependence. He should not be drilled into possibly 
uncongenial work in company with others, but allowed to find 
his own interests. The doctor may deem it desirable tactfully 
to instruct the patient that he can cure himself in this way. 

An open-air life is best, with plenty of opportunity for occupa- 
tion, exercise and games, into which he may sublimate his libido. 
The diet should be non-stimulating sexually, alcohol must there- 
fore be excluded and the allowance of meat restricted. From 
psycho-analytical considerations I would especially restrict pork, 
ham and bacon. Beef is undesirable for physical reasons. 

Lastly the patient should be psycho-analyzed if there is 
any possibility that his fits may be of hysterical origin (“ psycho- 
genetic epilepsy’’). Some hysterical fits present exactly the 
same features as true epileptic ones. 

These are ideal conditions impossible for the enormous number 
of epileptics in this country. The present position is that several 
epileptic colonies are in existence but that, for financial and 
other reasons, they are not equipped and staffed in such a way 
as to provide this ideal treatment. We can only hope that the 
recognition that epilepsy is a curable disease may induce some 
of our charitably inclined millionaires to place suitable epileptic 
colonies on a sure footing or—better—prompt our money- 
spending authorities to divert some of their useless expenditure 
into soul-saving channels. 


CHAPTER AIT: 
ALCOHOLISM, 


WE have seen that both epilepsy and dementia pracox are 
psychoses whose function is to aid their victims to fulfil a desire 
to retreat from the world of reality in one way or another. 
Some people achieve the same end by taking excessive quantities 
of alcohol or drugs, especially those which induce sleep or, short 
of this, benumb consciousness to such an extent that it permits 
the unconscious to fulfil its wishes, either in phantasy or in such 
activities as would not be tolerated by these people under 
normal conditions. 

As a paradigm let us consider alcohol. The inclination to 
drink too much can usually be ascribed to conviviality or re- 
peated attempts to drown some sorrow. In both these circum- 
stances the alcoholic drinks enough to let his unconscious have 
its fling and thus finds happiness; but inasmuch as conviviality 
and profound grief do not invariably lead to alcoholic excess or 
even mental abnormality of any other kind, there must be 
some deeper-lying cause. This has been revealed by psycho- 
analytic investigation of such patients; for it is found that all 
alcoholics and drug-takers have a large homosexual complex. 
Homosexuality is an intolerable idea, conflicts with conscious 
trends of thought and is therefore repressed. Whenever it 
subsequently escapes the repression it is bound to give rise to 
intrapsychic conflict. This is too much for the individual to 
bear and he therefore seeks comfort in alcohol, morphia or some 
other drug. The manner in which these achieve their object 
varies from patient to patient, and it can only be revealed by 
psycho-analysis. 

It is not to be understood from the above remarks that every- 
body who takes a glass of wine with his meals or likes a tot of 
whisky at night is a repressed homosexual. They refer only to 
those people who feel a need for alcohol, those—for example— 
who imbibe enormous quantities towards “ closing-time’’ to 
tide them over the “ dry ”’ period. During the War such persons 
suffered so much from the restrictions of the Liquor Control 

372 


‘ALCOHOLISM 373 


Board that many experienced an attack of delirium tremens 
for the first time as a direct result of those restrictions. 

Whether alcohol is imbibed in small or large doses, the aims 
and results are the same. In small doses it temporarily 
obliterates from the memory the many little worries of life and 
therefore serves the useful purpose of helping man to adapt 
himself to his environment. When he drinks large quantities, 
our conclusion must be that he has much more troublesome 
and serious conflicts to face, or efface, than the majority of his 
fellows. In neither case is the individual fully aware of the 
nature of the wish he is fulfilling (the conflict he is solving) by 
drinking alcohol and therefore the reason why he takes it is 
unknown to him—it is unconscious. But all know that alcohol 
brings peace of mind and this psychological activity of the drug 
must never be forgotten by those who have to minister to patients 
suffering from physical diseases, either in hospital or in private 
practice. 

Not every case of mental disease with a history of previous 
alcoholic excess is caused by alcohol. Many attacks of insanity 
are ushered in by an alcoholic bout, this being a symptom and 
not a cause of the disorder. Again there are cases of mental 
disease not to be classed as intoxication insanities, although 
they owe their origin to degeneration of the nervous system 
induced by alcoholic excesses. Of this nature are some cases of 
epileptic insanity and intermittent insanity (mania and melan- 
cholia). Alcohol also plays an important réle in the causation 
of some cases of arterio-sclerotic insanity, senile dementia and 
perhaps general paralysis. 


TREATMENT OF ALCOHOLISM. 


The question naturally arises whether alcoholism can be 
either prevented or cured. 

Prevention could best be achieved by education. By this I 
do not mean useless lectures on the evils of ‘alcohol, but the 
training of children in such a way that they will not feel the need 
of alcohol or any substitute for it when they grow up. This is 
admittedly a very great problem requiring, among other factors, 
a similar education of the parents during their earliest years. 
It ought not to be necessary that every individual of an ideal 
community should be a total abstainer in order to avoid being an 
alcoholic. 

Another suggested method is the total abolition of alcoholic 


374 MIND AND ITS DISORDERS 


beverages, so that they are unprocurable. The United States 
of America have already adopted this expedient. The experi- 
ment should prove interesting; for it seems to the writer that 
those people, whose mental conflicts are such as would cause 
them to seek relief in alcohol, must either turn to some worse 
drug or solve their conflict through psychosis. I understand 
that the truth of this dictum is manifesting itself in America 
even earlier than I had expected. When war conditions in this — 
country necessitated the requisitioning of distilleries and breweries 
as munition factories the Board of Liquor Control acted wisely 
in the author’s opinion by limiting the output of alcohol without 
abolishing it; but prolongation of even limited restrictions 
would presumably lead to some form of mass paranoia. Indeed 
there is still a mysterious “industrial unrest”, and it is 
probable that total prohibition in Russia played an important 
role in the production of the present state of anarchy in that 
great country. 

The psychological mechanism is interesting. Should revolu- 
tion break out, the people would never admit, even to them- 
selves individually, that their actions were due to the inaccessi- 
bility of or repressed desire for alcohol; such an idea would be at 
once repressed and find an outlet in some form of mass psychosis 
(revolution, for example). Any Government or body of men 
seeking to toy with the habits of a nation should avail them- 
selves of the services of a practical psychologist before putting 
their ideas into execution. 

The cure of alcoholism is only possible when the patient 
himself is anxious to be cured and is prepared to co-operate in 
the process. 

There are a few medicines which have a reputation for diminish- 
ing or abolishing the desire for alcohol, such as sodium bromide 
in large doses (20 grains three times a day), strychnine, apomor- 
phine hypodermically and tincture of capsicum by the mouth. 
In mild cases they are undoubtedly helpful, but in more severe 
cases we have to resort to psychotherapy. 

In a few very rare cases the patient succeeds in relinquishing 
his habit without any outside aid, his self-respect serving as a 
sufficiently strong motive. As a rule, however, he requires 
assistance which can be given in one of two forms: psycho- 
analysis or suggestion. The first teaches the patient to under- 
stand himself and is therefore fundamental; but unfortunately 
it takes a very long time (daily for at least six months). The 
second, which is given cither in the sleeping or waking state, 


ALCOHOLISM 375 


has the disadvantage that it makes the patient permanently 
dependent on the physician. The hypnotic treatment is given 
daily for a week or two, then on alternate days, then twice 
a week, once a fortnight and so on to once in six months. 
Whichever method is adopted, however, we find that many 
patients discontinue it too soon and consequently relapse. No 
treatment is successful without the patient’s cordial co-operation 
toa finish. | 

A curious latter-day treatment is the production of a delirious 
state for several days by maximal doses of hyoscine; I have no 
experience of the method. 


GHAPIER SAI: 
SOME OTHER DRUG HABITS. 


THESE are psychoses whose psychopathology and general treat- 
ment are the same as those of alcoholism as described in the 
previous chapter. 


MoRrPHINISM. 


Etiology.—The abuse of opium and its alkaloid morphia is less 
frequent than alcoholism because these drugs are more expensive 
and less easy of access to the general public than alcohol. 
Accordingly we find morphinism most frequently among medical 
students and practitioners, dentists and nurses, who have experi- 
ence of the drug and little difficulty in obtaining it, and among 
the wealthier classes to whom expense is no obstacle. 

Begun in the first instance for the relief of insomnia or some 
frequently recurring pain, the morphia habit may become 
confirmed in less than six weeks, so that the patient is not only 
unable to discontinue the use of the drug but is obliged to resort 
to it in ever-increasing doses. In a few patients the habit is 
started by a single dose taken either to see what the sensation 
of morphia intoxication is like or to stimulate cerebral activity 
for the purpose of getting through an increased amount of 
mental work. More than three-fourths of the patients are men 
and the habit is usually contracted in the third or fourth decade 
of life. 

In its physiological action morphia diminishes all secretions 
except the sweat and it is a motor sedative. The drug has 
therefore a pronounced action upon the functions of the ali- 
mentary canal; it causes dryness of the mouth, disturbs the 
digestion, diminishes the appetite for food and induces con- 
stipation. The pulse-frequency is diminished and the blood- 
pressure lowered by dilatation of the peripheral arterioles. The 
dilatation of cutaneous vessels causes a feeling of warmth. 
The respiration becomes shallow and the bronchial secretion is 
diminished. The pupils are strongly contracted. 

In its specific action upon the nervous system morphia is a 
local anesthetic and anodyne. By its action on the cerebral 

370 


ABSTINENCE FROM MORPHIA ST 


cortex it produces a peaceful feeling of happiness and comfort 
and it stimulates the imagination, in this way increasing the 
capacity for mental work. In the later stages of its action, if 
taken in sufficient quantities, it promotes sleep. 

When taken habitually, the organism acquires an increasing 
tolerance for the drug so that the administration of larger and 
larger doses becomes necessary to procure the above results. 
It may be presumed that this tolerance results from the forma- 
tion by the tissues of protective substances antagonistic to the 
action of morphia. If Marme’s statement be correct that the 
antagonistic substance is oxy-di-morphine, we may conclude 
that the antagonistic action of the organism consists in an attempt 
to oxidize the morphia introduced into the system. 

Abstinence Symptoms.—Whatever the above natural antidote 
to morphia may be, it must be held responsible for the symptoms 
which arise when a morphinomaniac is suddenly deprived of his 
usual dose. 

The symptoms are those of poisoning by a perfect antidote 

to morphia. There is increase of all the secretions of the body 
except the sweat and there is general hyperesthesia of the skin 
- and mucous membranes. Consequently vomiting and diarrhoea 
with tenesmus are prominent symptoms and many patients can 
retain only liquid food. There is also a slight “‘ cold in the head ” 
with troublesome sneezing, salivation and slight cough. Uncon- 
trollable yawning and hiccough also occur. 
. The pulse-frequency is increased and the blood-pressure raised 
by contraction of the peripheral arterioles. On account of the 
contraction of the cutaneous vessels, the patient feels cold and 
asks for extra blankets. Some patients complain of feeling cold 
internally. Palpitation and syncope are liable to occur, the 
latter being one of the gravest symptoms which the physician 
has to combat in the treatment of these patients. 

There is hypereesthesia of all the senses; the patients complain 
that the light is too strong and that there is too much noise 
going on around them. Some suffer from neuralgic pains and 
other unpleasant sensations in various parts of the body; lights 
appear before the eyes and there is singing in the ears. 

Muscular debility and a sense of fatigue set in, so severe in 
some cases that the patient is scarcely able to stand. If he be 
asked to extend his fingers, they are seen to be tremulous. 
Muscular twitchings and cramps occur in the limbs; even general 
convulsions are reported by some observers. General motor 
restlessness is a constant symptom which, in some patients, 


378 MIND.AND ITS DISORDERS 


attains the severity of true maniacal excitement for a short 
period, perhaps with suicidal or homicidal impulses. The super- 
ficial and tendon reflexes are greatly exaggerated. 

The emotional attitude of the patient is one of abject misery; 
and it is this mental depression associated with absolute insomnia, 
more than any other symptom, which induces patients to abandon 
the attempt to get rid of the morphia habit, knowing as they 
do that a single injection of the alkaloid will alleviate all their 
troubles. 

Morphia habitués are unreliable, incapable of persistent appli- 
cation to work, untruthful, depraved, immoral and lable to 
excesses of debauchery. After many years, insanity (usually 
melancholia) may be the result of chronic intoxication by 
morphia. 

Often and again does the morphinomaniac determine to end 
his ways and give up his habit, but the alkaloid and the syringe 
are at hand and the temptation invariably proves too strong. 
He may make a determined effort, pour his stock of morphia 
down the sink and break his syringe; but he finds he has to 
contend with more than the force of habit. Abstinence symp- 
toms arise and become intolerable. A new syringe and stock of 
morphia have to be purchased and the patient learns that he is 
a slave to the drug, body and soul. 

Diagnosis.—The diagnosis of morphinism rarely presents any 
difficulty. The patient usually comes under observation with. 
a definite history of the habit and with the request to be cured. 
Moreover, the alkaloid may be detected in the urine and there 
are commonly to be found many scars of old abscesses caused 
by the use of a dirty hypodermic syringe. Should any 
doubt arise, the diagnosis is easily cleared up by placing 
the patient in circumstances in which he can have no 
possible access to the drug. Abstinence symptoms are sure to 
appear within twenty-four hours if the patient is addicted to 
morphia. 

Prognosis.—It is said that the morphia habit does not tend 
to shorten life. On the other hand, the possibility of a complete 
cure without subsequent relapse is small (10 per cent. of the cases, 
according to Kraepelin). The outlook is better for those patients 
who have been accustomed to take their morphia in the form of 
opium than for those who take the pure alkaloid, better for 
those who take it by the mouth than for those who take it 
hypodermically and better for those who take morphia alone 
than for those who take other drugs with it. 


TREATMENT OF MORPHINISM 379 


Treatment.—It is advisable at the outset to warn the patient 
that he must be prepared to endure a considerable amount of 
suffering while he is being cured, at the same time assuring him 
that every effort will be made to mitigate his symptoms. He 
should also be told how long the acute stage of his illness will 
last, about five days if morphia is completely withheld from 
the first. By thus dispelling all doubt, one important source of 
restlessness is removed. 

The patient is then put to bed and carefully examined in 
order to ascertain, inter alia, that he has no morphia secreted 
about him. The room should be quiet, warm and well ven- 
tilated and the bed should not face the window, which ought to 
be supplied with a blind. 

The diet is nourishing and consists mainly of liquids (milk and 
broths) so as to avoid gastro-intestinal irritation and to promote 
urinary secretion. 

The weaning of the patient may be accomplished slowly, 
rapidly or abruptly. With the slow method the dose is daily 
reduced by about one-tenth. Thus, a patient whose habitual 
dose had been 30 grains daily would during treatment receive on 
mieesivedaye 27, 24,22)20;18,'16, 14, 12; Ir, 10,9, 8, 7, 6,75; 
4k, 3, 24, 2, 14, 1, 2, 4, 4 grains, the drug being then discontinued. 
In the rapid method the dose is at first reduced by nearly one-half 
daily. Erlenmeyer gives the following table: 


RAPID METHOD OF WEANING. 


Habitual Dose | e10=3004 30-40.) -40-50,.} O+50-i, |, - 1-2; 

i Ce g. Cg Gr Gr. 

First day et 8 I5 | 25 30 cg 50 cg 
Second _,, ~ 2 | 6 $2) Pabe1 5) 8 20 30 
Third _,, biel we 10?) Mh 12's 4) PS 20 
Fourth ,, 3 6 Fo ste 12 15 
Fifth % 2 4 4 8 | 10 
Sixth ig I 3 x 6 | 6 
Seventh ,, — 2 2 4 bss 
Eighth _,, — I I 2 2 
Ninth ,, oa — — I I 


In the abrupt method no morphia is allowed from the moment 
when treatment is commenced, unless syncope or some other 
form of collapse threatens, when one or two injections of $ grain 
each are administered in order to tide the patient over the 
danger. To the author this method appears to be the least 
objectionable unless the previous dosage has been more than 


380 MIND AND ITS DISORDERS 


10 grains a day; because, although the illness is more severe, it 
is less trying to the patience of the sufferer. Whichever method 
is used a hot bath greatly conduces to the comfort of the patient 
and should be given night and morning. 

Further to alleviate the patient’s sufferings during this trying 
time certain drugs have been recommended as temporary sub- 
stitutes for morphia, viz., alcohol, chloral and especially cocaine. 
Cocaine has been greatly praised by Berkley and Obersteiner. 
If used, the dose should never exceed 10 grains daily, it should 
be given by the mouth and the patient should on no account 
be allowed to learn the nature of his medicine. The morphino- 
maniac is usually well acquainted with the literature of his 
disease and, all too often, he attempts to cure himself by taking 
to cocaine. The remedy is worse than the disease, for the 
invariable result is that he becomes a slave to two drugs instead 
of one. More recently meco-narceine (Duquesnel’s solution) 
and combretum sundaicum have been recommended in the 
substitution treatment of morphinism. The latter drug has 
been used as a cure for the habit in the East; 17 minims of the 
liquid extract three times a day corresponds to the dose taken 
by the natives. I have tried it on patients without being 
impressed by the property ascribed to it; but I am rather averse 
from substitution treatment of any kind. It is too lable to 
give the patient a superadded drug-habit. 

Insomnia should be combated by a different hypnotic e every 
night, the changes being rung on paraldehyde, amylene hydrate, 
dial, sulphonal, trional and chloral hydrate. Bicarbonate of 
soda is an invaluable remedy for the relief of gastric hypersecre- 
tion and hyperacidity and should be given as a routine medicine. 
Erythrol tetranitrate may be given in }-grain doses to lower the 
pulse tension if necessary, and digitalis is useful to restore a 
failing heart. When the circulation is in danger, however, and 
collapse threatens, the author is in the habit of resorting to 
morphia. Here, as in the case of alcohol, the safest and most 
certain remedy for the patient is “‘a hair of the dog that 
bit him ”’. 

During treatment the patients lose much weight, which is 
more than regained during convalescence as they gradually 
return to a normal diet. Convalescence should be prolonged to 
three or four months at least in order to allow time for restoring 
the nervous system and to establish the habit of doing without 
the drug. 

In the meantime some form of psychotherapy should be 


DRUG HABITS — 381 


initiated. The only gratifying results are obtained from a 
complete psycho-analysis which invariably reveals the patient 
to be fixated at the auto-erotic-homosexual level. 


COCAINISM. 


Etiology.—The cocaine habit arises in much the same way as 
the morphia habit, but it has an additional etiological factor 
in that morphinism predisposes to it. Morphinomaniacs take 
to cocaine either as an adjuvant or as a substitute for morphia 
or as a local anesthetic prior to an injection of morphia. I have 
been struck by the large number of cases of cocainism started 
by an attempt to relieve the discomfort associated with diseases 
of the nose. 

The physiological effects of cocaine are largely induced by its 
stimulating action on the sympathetic system. It raises the 
blood-pressure by contracting the peripheral arterioles and in- 
creasing the frequency of the pulse. In the same way it dilates 
the pupils, causes retraction of the eyelids and induces proptosis 
by the stimulating effect upon Miiller’s muscle. Glandular 
activity is increased throughout the organism. Locally applied 
it causes anesthesia of the part by cutting off the blood-supply 
from the peripheral nerve-ends. 

In its action on the cerebral cortex cocaine reduces fatigue 
and causes motor restlessness and excitement. It drives away 
care and induces a pleasant feeling of peace and well-being. It 
appears to have a special action on the writing centre, for cocaine 
habitués write interminable letters which may be abnormally 
brilliant just after an injection. Association of ideas is facili- 
tated and memory and judgment are improved. The drug 
destroys the appetite for food. One patient, addicted to cocaine 
alone, told me that it destroyed the desire for sweet articles of 
diet, whereas he had a craving for sweets when he was deprived 
of the drug; medical psychologists will appreciate the deeper 
meaning of this symptom. Large doses cause muscular spasms 
especially of the face. 

Cocainism is almost invariably associated with morphinism, 
addiction to cocaine alone being rare. It is remarkable that, 
although sudden abstinence from cocaine causes much less dis- 
tressing symptoms than abstinence from morphia, the former 
is much more difficult to renounce and the proportion of relapses 
after apparent recovery is greater. 

The abstinence symptoms are dryness of the mouth, apepsia 
and constipation, muscular weakness with tremor, especially of 


382 MIND AND ITS DISORDERS 


the tongue, diminution of the pulse-rate with fall of blood- 
pressure and a tendency to syncope. 

Some patients complain of pains in the limbs, mostly in the 
neighbourhood of joints; but most characteristic is formication 
of the hands, a sensation of small worms or ants crawling under 
the skin. Black specks, which may also be mistaken for small 
insects, float before the eyes and there may be hallucination of 
hearing. | 

The association of ideas is uncontrolled, volition is weak and 
the memory for recent events, even for weeks back, defective. 
In conjunction with a general feeling of depression the judgment 
is warped, so that the patients get the idea that the hand of 
every man is against them; they become anxious and fear all 
manner of impending harm. Especially are wives distrusted 
and accused of infidelity (‘‘ cocaine paranoia’’). The patients 
are often impulsive and violent; they may wilfully destroy 
valuable property by reason of some fantastic delusion; they 
may murderously attack their supposed persecutors or commit 
suicide in order to escape them. 

The abstinence symptoms appear to be, as with morphia, due 
to intoxication by a perfect antidote to cocaine, formed by 
the tissues—it is reasonable to suppose—in their attempts to 
counteract the evil effects of the drug. 

The usual clinical picture of the cocaine habitué presents the 
above symptoms of cocaine poisoning and cocaine abstinence in 
a confused mass, sometimes one symptom, sometimes another 
becoming the more prominent according to the recency and 
magnitude of the last dose. 

Diagnosis.—The history of cocainism is seldom wanting. In 
its absence the diagnosis may be difficult, but the same principles 
are to be applied as in the diagnosis of morphinism. Formica- 
tion of the hands is more than suggestive. Cocaine paranoia is 
to be distinguished from alcoholic paranoia by the greater 
rapidity of its onset and course. 

Prognosis.—Temporary recovery from cocainism usually takes 
place after a few months of enforced abstinence, the acute 
symptoms passing off within the first few weeks. The drug is, 
however, so enslaving that relapse occurs even more frequently 
than with morphia. Cocaine paranoia is liable to last several 
months and a few patients become permanently insane. 

Treatment.—The same principles of weaning the patient apply 
as in the case of morphia, but there is less danger of collapse 
during treatment. The same hypnotics may be used and nux 


DRUG HABITS 383 


vomica with hydrochloric acid may be given as a routine medicine. 
Similarly, psychotherapy is almost invariably required to com- 
plete the cure. 


CHLORALISM. 


In these days of insomnia it is not surprising to find that the 
drugs which the average man finds most alluring are the hypno- 
tics. Morphia has the greatest number of adherents. A few take 
to chloral (usually women), paraldehyde, sulphonal and others. 

When a person habitually uses chloral his organism gradually 
becomes inured to the usual dose, which then proves insufficient 
- to produce the normal physiological effect, presumably on 
account of an increased formation of antibodies of some kind 
or other by the tissues. 

If at this stage the patient is prepared to put up with several 
sleepless nights he may be able to throw off the chloral habit; 
but this is too much to expect from human nature. Increasingly 
larger doses are taken at first nightly, then during the day as 
well, until a definite attack of insanity supervenes. This is 
apparently due, not directly to chloral, but to the above- 
mentioned antibodies; for the phenomena are precisely the 
same as those which arise when the habitual ingestion of chloral 
is abruptly suppressed. 

Symptoms.—Mental disorder arising from the chloral habit 
occurs in one of three forms: 

1. Motor excitement and agitation with hallucinations of 
vision and hearing, especially in the evening, and sometimes 
with epileptiform attacks. 

2. Depression with heaviness, torpor and muscular weakness, 
which may also be complicated by hallucinations; and 

3. Delirium tremens which, in the absence of a history, can 
only be differentiated from alcoholic delirium tremens by the 
odour of chloroform in the breath. 

Insomnia occurs in all three forms. Some patients complain 
of irritation of the skin, pains in the joints and dyspepsia. 

Prognosis. Recovery occurs after prolonged abstinence. 
The literature of the subject is too meagre to allow of our deter- 
mining whether there is much tendency to relapse. Besides, 
chloral has rather fallen into popular disrepute among the multi- 
tude of latter-day hypnotics. 

Treatment.—It is said that the patients are liable to syncope 
and that the abrupt method of weaning is therefore inadmissible ; 
but, if the patient appears to be in fairly good general health, 


384 MIND AND ITS DISORDERS 


the rapid method mentioned in the account of the treatment of 
morphinism may be employed; if not, the physician should 
resort to the slow method. 


PARALDEHYDISM. 


I have met with a few instances of intemperate addiction to 
paraldehyde, two of which came under my observation as certi- 
fied cases of mental disease. | 

The patients suffer from great motor excitement with occa- 
sional violence, tremor of the lips and tongue with disturbance 
of articulation and fibrillary tremor of the muscles of the chest. 
Some exhibit tremor of the fingers. There is marked impercep- 
tion with loss of memory and the patient may be unable to 
recognize his former acquaintances; hallucinations of vision and 
hearing occur. 

Physically the most striking symptom is a profuse bronchor- 
rhoea which may persist for a week or more after the last dose 
of paraldehyde. 

_ When the excitement subsides the patient falls into a condition 
of extreme lassitude which gradually passes off as convalescence 
is established. 

Prognosis.—All of my patients made a complete recovery, 
with the exception of one who remained in a state of mild 
dementia. So far as I am aware, none of the cases has relapsed. 

Treatment consists of complete suppression of the drug, the 
mitigation of symptoms on general medical principles and over- 
feeding. 


CHRONIC SULPHONAL POISONING. 


This condition is occasionally met with. Hamatoporphyrin- 
urla is the most common symptom; but sometimes the friends 
seek the advice of the medical man because the patient is always 
asleep and is supposed to be suffering from “‘ sleeping sickness ”’. 
The latter disease is excluded and the physician put on his guard 
by the absence of trypanosomes from the blood. The diagnosis 
is cleared up by placing the patient in circumstances in which 
he can have no possible access to drugs: the sleepy condition 
then passes off. Some of the patients have a shuffling or stagger- 
ing gait. I had one case of chronic cortical atrophy in a woman 
of fifty, apparently caused by taking large doses of sulphonal 
every night for sixteen years. The patient passed out of my 
hands and I learned that the ultimate issue was fatal. 

During* treatment the patient should be kept in bed. No 


DRUG HABITS 385 


untoward symptoms arise from the abrupt suppression of sul- 
phonal. Convalescence is established after a few sleepless nights, 
which do no harm. 


CANNABIS INDICA POISONING. 


Indian hemp is largely taken in the form of haschisch by the 
natives of India, Persia, Asia Minor and Egypt for the purpose 
of inducing pleasurable motor excitement and hallucinations, 
which are commonly sexual in character among Eastern races. 
Hallucinations of vision are also common. 

The drug also causes epigastric sensations with anzsthesia 
of the arms and legs. The time-sense is impaired in such a way 
that time appears to pass slowly. 

The pulse is frequent and of low tension; the face is pale and 
the pupils are dilated, but they react to light. 

Acute intoxication by haschisch is characterized by drowsiness 
with a pleasant feeling of exaltation and happiness. The sense 
of fatigue is abolished. The gait is sometimes staggering, as in 
alcoholic intoxication. 

Acute delirium sometimes occurs as the result of chronic 
haschisch poisoning. This is characterized by hallucinations of 
all the senses, accompanied by delusions of persecution or of 
exaltation. The patients are restless and sleepless, but not to 
the same extent as those suffering from alcoholic delirium. 

Dr. Warnock, in the Journal of Mental Science for January, 
1903, states that acute mania from haschisch varies “‘ from a 
mild short attack of excitement to a prolonged attack of furious 


mania, ending in exhaustion or even death’’. The patients 
suffer from delusions of persecution or of grandeur. Gustatory 
and auditory hallucinations are not uncommon. “A certain 


impudent, dare-devil demeanour is a characteristic symptom.’ 

Chronic delusions of persecution and chronic mania sometimes 
occur. If hallucinations are experienced, they play an un- 
important role. 

Lastly chronic dementia develops with amnesia, apathy, 
degraded habits and loss of energy. 

Under the name “ cannabinomania’’ Warnock describes the 
mental condition of haschisch users between their attacks of 
acute insanity. ‘‘ They are good-for-nothing, lazy fellows who 
live by begging and stealing, and pester their relations for money 
to buy haschisch, often assaulting them when they refuse their 
demands. The moral degradation of these cases is their most 
salient symptom; loss of social position, shamelessness, addiction 

25 


386 MIND AND ITS DISORDERS 


to lying and theft, and a loose, irregular life, make them a curse 
to their families.”’ 

It is clear that some of these mental disorders are psychotic, 
the drug playing but a secondary role. The patient has some 
terribly serious mental conflict to solve and he seeks its solution 
vid Cannabis indica as well as vid psychosis. 


BELLADONNA AND ATROPINE POISONING. 


Belladonna and its alkaloid atropine are liable to give rise to 
mental symptoms if taken in poisonous doses. In a few patients 
with idiosyncrasy for the drug these symptoms may be induced 
by so small a dose as that used in atropizing the eye as a pre- 
liminary to estimating a refraction. 

Excluding criminal cases, poisoning usually occurs either from 
eating belladonna berries or from taking a medicine in which the 
liniment has been accidentally used instead of the tincture. 

The physical signs are dryness of the throat, a scarlatiniform 
rash and dilatation of the pupils with paralysis of accommoda- 
tion. The pulse is greatly accelerated and fainting may occur. 

The characteristic mental symptom is visual hallucination. 
This has a special tendency to take the form of threads, hairs, 
wires and similar objects. There is busy delirium, the patient 
occupying himself by apparently picking threads out of the tips 
of his fingers, sewing with needle and thread or plucking fruit 
from a tree and eating it. In severe cases complete unconscious- 
ness occurs. 

The symptoms usually subside in the course of three or four 
days, but the memory may be defective for a week or more. 

Treatment consists of washing out the stomach and administer- 
ing a solution of tannic acid, perhaps in the form of stewed tea, 
in order to precipitate the alkaloid. A hypodermic injection of 
morphia mitigates most of the symptoms. Pilocarpine is also 
recommended. | 


ETHER INEBRIETY. 


In some villages in North Ireland and in East Prussia certain 
beverages adulterated with ether find favour among the poorer 
classes on account of the hilarious intoxication which they 
rapidly induce at a small cost. Half a pint of ether per diem is 
not uncommon. There is sudden exhilaration with motor excite- 
ment which rapidly passes off, leaving the patient dull and 
stuporose. He sleeps the drug off and is apparently none the 


DRUG HABITS 387 


worse next day for his drinking-bout. Usually he is an old 
alcoholic, so that it is difficult to ascertain the specific effects of 
chronic ether intoxication; there seems to be a tendency to 
melancholia. The underlying unconscious psychical mechanisms 
are the same as in other drug habits. 


PLUMBISM. 


The mental phenomena induced by chronic lead-poisoning are 
those of uremia and are directly dependent on chronic renal 
disease simultaneously induced by the poison. 


TOXIC INSANITY. 


UNDER this title we have to consider mental disorders due to the 
noxious influence of the products of disease, mainly infectious, 
and of certain drugs, especially alcohol, to which a separate 
chapter is assigned. 

Inasmuch as the array of symptoms caused by excessive mental 
and physical exertion, conscious worry, anxiety and fright is 
precisely the same; the description of the insanity arising from 
such causes is also included here, the question whether such 
conditions may induce the formation of toxins or not being left 
open. It would appear probable that they do; at least we 
know that the adrenalin and sugar contents of the blood are 
altered by such affective states. 


CHAPTER XIV. 
ACUTE CONFUSIONAL INSANITY. 


(MENTAL EXHAUSTION AND INTOXICATION.) 


In the earlier part of this volume it was stated that there are 
certain individuals who, when they become fatigued, suffer from 
a train of exhaustion symptoms, exhaustion being pathological 
fatigue. Should such people suffer from mental disease it tends 
to fall into line with the type now under consideration. 

The mental disorders here described arise in predisposed 
individuals as a result of severe intoxication of the cerebral 
cortex by alcohol, belladonna, cocaine, chloral, Indian hemp 
and other drugs; by the toxins of certain fevers, such as ery- 
sipelas, influenza, rheumatism, typhoid, scarlet fever and septi- 
cemia, and still more by the antibodies formed during such in- 
fectious diseases;* by products of fatigue, which are created by 
excessive mental or physical exertion, worry, anxiety and fright, 

* Bérard and Lumiére have described this condition as occurring in 
eleven cases of tetanus treated with antitetanic serum. It is fortunately 
of brief duration lasting only fifteen to twenty days. 

388 


ACUTE CONFUSIONAL INSANITY 389 


or as a result of malnutrition of the cortex from inanition, 
anemia or profuse hemorrhage. Childbirth is a frequent cause 
of the disorder since it may lead to exhaustion, hemorrhage or 
septicemia; this insanity may also be caused by prolonged 
lactation. 

Neither from my own observations nor from a careful study 
of Bonhoeffer’s monograph on “ Die Symptomatischen Psy- 
chosen’ have I been able to convince myself of any features of 
the disorder which can be regarded as even suggestive of any 
specific etiological factor except, perhaps, in the case of some 
poisons. The specific origin of the malady can be ascertained 
only from the history or from the coexistence of symptoms of 
some particular physical illness. 

Physical Signs.—The patients look ill from the beginning. 
Their complexion is pale and muddy. In depressed cases the 
skin tends to be abnormally dry, in excited cases greasy. In all 
there appears to be a special proclivity to seborrhcea sicca of 
the scalp. 

The general nutrition is poor. The patients lose weight and, 
on admission to hospital, are frequently emaciated. The tem- 
perature is often subnormal. 

There is almost invariably a slight chlorosis. The pulse is soft 
and the arterial tension low, even in the depressed cases; the 
pulse-rate is normal or only very slightly increased. The urine 
is scanty, of high specific gravity, and it may contain a trace of 
albumin. 

As a rule, there is little or no diminution of muscular power; 
yet a few patients are physically weak and show tremor of the 
fingers. 

The superficial reflexes are normal except in depressed patients, 
in whom they are diminished. The tendon reflexes are increased, 
the knee-jerk being usually characterized by large excursion and 
inactive return. The organic reflexes are unaffected. 

The pupils are widely dilated, but react to light and contract 
on convergence. Nystagmoid jerking is commonly seen on 
extreme lateral deviation of the eyes. 

Mental Symptoms.—Peripheral analgesia is almost invariably 
present during some stage of the disease, is one of the cardinal 
symptoms and persists usually for a fortnight or more after 
the patient comes under treatment. Contraction of the visual 
fields may be sometimes observed; possibly it is a constant 
symptom, but it is difficult to determine SAMS ASLOLLY aes 
it is present in all cases. | | 


390 MIND AND ITS DISORDERS 


The analgesia can be overcome by certain devices. For 
example, if a spot not too far from the margin of the analgesia 
be persistently stimulated by repeated pin-pricks, the patient 
soon begins to apprehend the painful element in the stimulus. 
Similarly, spots can be discovered where he cannot feel the pain 
of an ordinary pin-prick but can feel the prick of a multiple- 
pointed pin.* We shall see later that this observation helps 
to elucidate the mechanism of the symptoms of this disorder. | 

There is a great disturbance of the functions of perception, 
cognition and recognition. Imperception occurs. If the patient 
be shown a picture he is unable to say what it portrays. Of 
course, the complexity of the picture necessary to elicit the 


Fic. 62.—ANALGESIA IN A CASE OF ACUTE CONFUSIONAL 
INSANITY. 


symptom varies from case to case. Similarly the patient may 
not be able to understand the import of a more or less com- 
plex sentence. 

Perceptual or ideational inertia is common. If the patient 
be shown a series of objects, he may recognize the first one and 
name it correctly, but give all succeeding objects the same 
name (vide p. 126). 

Hallucinations are a cardinal symptom. Commonly they are 
of all the senses. The patients see in the air moving faces, devils 
or flying insects, hear voices or other sounds; sometimes they 
catch imaginary insects with their hands and evidently feel 


* Such an implement can easily be made by pressing the points of four 
or five ordinary pins through a disc of cork. 


ACUTE CONFUSIONAL INSANITY 391 


them between their fingers; they feel beetles crawling over them, 
smell chloroform in the bedclothes and taste poison in their food. 
Illusions of identity occur and the officials of the institution are 
mistaken for relatives or enemies. 

The patients are incapable of apprehending the nature of their 
surroundings. This again is a characteristic symptom of the 
disorder. Patients are, at least in severe cases, completely 
disorientated. Even in mild cases, they are liable to lose 
themselves in formerly well-known surroundings. 

The memory is greatly disordered. Most of these patients 
have no idea how long they have been in hospital and women who 
have been married for years will answer to their maiden name 
only. On recovery it is found that a great part of the illness is 
forgotten and remains a mere blank, a mental scotoma. 

This extensive disturbance of the perceptive faculties leads to 
disorder of judgment and delusions arise. The patient refuses 
to accept the reality of things. The hospital is a church, 
monastery or theatre. Although in his own room and bed, he 
believes that he has been transferred elsewhere and that an 
elaborate attempt has been made to make the place resemble his 
ownroom. The flowers in the room are artificial; the newspapers 
are not brought from the outside world, but printed on the 
premises for purposes of deceit, the news therein being false. One 
patient, whom I allowed to examine my camera minutely, 
refused to believe that it was a real one. Others believe that 
their children are being tortured, for they can hear them scream- 
ing; that they themselves are to be done to death, for they see 
cartloads of bodies taken away every night; or that certain 
relatives are dead, for they have been present at the inquest. 
Expansive delusions occur in a few cases. 

The emotional attitude varies. The majority are depressed. 
Many are cheerful, abnormally hilarious and mirthful. Emo- 
tional reaction is excessive in most cases, the patients being 
irritable -and liable to outbursts of laughter, anger or depres- 
sion associated with a flood of tears. A few stuporose patients, 
on the other hand, appear to be completely apathetic. 

Instinctive action is uncontrolled. In many cases the peri- 
pheral anzsthesia allows the pelvic area to dominate conscious- 
ness, the patients then becoming erotic or taking to masturbation, 
thus exhausting themselves further and perhaps rendering their 
malady incurable. A few patients, especially males, collect 
rubbish. Destructiveness is common, the bedding and clothing 
being frequently torn to pieces. 


392 MIND AND ITS DISORDERS 


On the other hand, the instincts are often in abeyance to such 
an extent that the patient is wet and dirty in habit. He spits, 
throws food about and smears his room with faeces. 

Motor restlessness is the rule, especially during the first month 
of the illness, so that the patients have to be nursed in a padded 
room. Excited cases lie on the floor and pound it with their 
heels and fists, or stand hammering with their closed fists on the 
walls or door. Depressed patients wander about aimlessly in 
a dazed condition, perhaps pulling out their hair; or they lie 
quietly but rigidly in bed gazing at the hallucinatory forms 
about the room. Others again curl themselves up in a corner 
under bedclothes or inside their nightdress and remain motion- 
less for hours together. Most of them resist all attentions, refuse 
food and have to be fed with a tube. 

The movements are slow and performed without any definite 
aim, thus differing from the characteristic movements of acute 
mania, which are quick and usually have some mischievous 


purpose. 
Agnostic and ideomotor apraxia occur, often with ideational 
inertia or “‘ perseveration’’. The patient is shown a fountain- 


pen; he pulls the end off. He is now shown a knife; he tries 
to separate it in the same way into two parts by pulling at the 
two ends. The same occurs with a match-box, and so forth. 

Volition being in abeyance, voluntary attention is impossible. 
Instinctive attention, on the other hand, is easily roused in some 
cases and the patient’s thought can be diverted by merely 
holding a watch, bunch of keys or other object within his field 
of vision. Of course, by reason of his imperception he may fail 
to grasp the full meaning and content of the percept which one 
endeavours thus to induce. 

On account of the lack of voluntary attention the speech is 
incoherent. In severe cases it may consist entirely of disjointed 
words and phrases. Rhyming incoherence is occasionally heard. 
A certain amount of garrulity occurs in some of the excited cases, 
but noisiness and shouting are rather exceptional. 

No attempt at letter-writing is made during the earlier stages 
of the disease. Later, when improvement develops, the patient’s 
first letters give evidence of mental confusion. He may start 
a letter fairly well; but as he rapidly tires the same sentences are 
repeated over and over again (ideational inertia) and the epistle 
ends in a series of disjointed phrases. The calligraphy is 
puerile, mistakes in spelling occur and blots are a frequent 
accompaniment. 


ACUTE CONFUSIONAL INSANITY 505 


VY ethdemn (hen 


Year Dad wre 


J “ware ae re 
 hocohaahs 


ay. fou u to PA hg reel 


eee OL, 4k ohale 


394 MIND AND ITS DISORDERS 


Sleep is poor and occupies but a few short periods during the 
earlier hours of the night. 

The acute stage of the disease lasts about three months, at the 
end of which it is found that sleep has improved under treatment 
and that analgesia has disappeared. The motor restlessness 
tends to decrease, but persists with occasional remissions for 
four or five months. During this time perception improves, 
the patient gradually becomes orientated and the hallucinations 
and delusions vanish. Even at this stage emotional outbursts 
are liable to arise and the patient is easily confused and may 
be incoherent in conversation. These symptoms, however, dis- 
appear during the next six months as the patient rapidly puts 
on flesh. Even during convalescence fatigue is easily induced 
and undue exercise is liable to bring about a relapse. 

Varieties.—At least five varieties may be recognized: 

I. The depressive form associated with motor restlessness. 
This is the commonest variety. 

2. The excited form, with happiness, hilarity, motor excitement 
and sometimes exaltation. 

3. The stuporose form in which the patient remains quiet and 
rigid, the rigidity affecting all the muscles of the trunk and limbs. 
These patients usually suffer from terrifying hallucinations, and 
are consequently in a state of extreme depression. 

4. Kraepelin distinguishes a separate variety which he calls 
“collapse delirium ’’. This is characterized by the shortness of 
its duration, since it rarely lasts more than a fortnight or a 
month. 

5. The catatonic form closely resembling the katatonia of 
dementia precox. Such patients present the symptoms of 
negativism, flexibilitas cerea, echopraxia, echolalia, antics, 
repetitive movements and verbigeration. 

There is an intermittent form of the disorder, the patient 
suffering from many attacks in the course of his life. Each 
attack leaves him more weak-minded and he ends in profound 
dementia. Analgesia is less constantly found in this class. It is 
possible that a more intimate study of this variety may cause 
many of the cases to be relegated to the maniacal-depressive 
group. 

Diagnosis.—The above varieties are to be distinguished from 
melancholia, mania, anergic stupor and dementia praecox by 
paying due attention to the state of the patient’s perceptive 
powers, orientation and memory. I regard it as the most 
difficult problem in the diagnosis of mental disease to differen- 


ACUTE CONFUSIONAL INSANITY 395 


tiate between the catatonic variety of confusional insanity and 
that of dementia przcox, especially when the patient does not 
speak and therefore gives no clue as to the state of his per- 
ception, orientation and memory. The presence of peripheral 
analgesia argues for confusional insanity. If the malady can be 
definitely ascribed to some recognized etiological factor of acute 
confusional insanity the fact should have considerable weight 
in making a diagnosis. In chronic cortical atrophy hallucina- 
tions do not occur. Certain epileptic states are liable to resemble 
this insanity, but in such cases a history of convulsions is usually 
obtainable. 

Prognosis.—The majority of these patients make a fairly 
complete recovery in six to twelve months. A few cases last 
longer, up to two years. About Io per cent. remain permanently 
demented. Kraepelin puts the duration at four months, the 
discrepancy being accounted for probably by the fact that bed- 
treatment is more rigidly adhered to on the Continent. The 
disease occasionally proves fatal. 

The best guide to prognosis is the depth of dissolution. Loss 
of control of the most recently acquired instincts is of minor 
importance. On the other hand, the prognosis is grave for 
patients who are persistently destructive and dirty in their habits, 
and for those who during the acute attack lose the instinct for 
speech and for locomotion. In estimating the probable duration 
of the disease the above rules do not seem to apply. The writer 
is fairly accurate, as a rule, in predicting the duration of a case, 
but unable to frame any rules; he can only ascribe this faculty 
to an intuition born of experience. 

Pathology and Morbid Anatomy.—While fatigue is an intoxica- 
tion of the tissues by the paralyzing products of muscular meta- 
bolism, exhaustion is regarded as a process of self-destruction of 
nervous tissue through its own activity, katabolism being in 
excess of anabolism. In other words, exhaustion is a morbid 
process taking place in the cerebral cortex, in which the amount 
of consumption exceeds that of repair. 

Such a condition of affairs can only exist where the supply 
of nutrient pabulum is deficient. Now the primary nutrient 
pabulum of the cortical neurons is the intracellular trophoplasm 
(chromatoplasm) and we learn that histological examination of 
the brains of patients who have died from acute confusional 
insanity reveals disintegration of the trophoplasm of the cortical 
neurons. The Nissl granules are deficient and powdery (chro- 
matolysis). There is in addition some staining of the achromatic 


396 MIND AND ITS DISORDERS 


substance and the nucleus may be eccentric in position (achro- 
matolysis). In some cases there is cedema of the pia-arachnoid 
and there may be found on microscopical examination diapedesis 
of leucocytes into the perivascular spaces. It is held that 
chromatolysis is a recoverable condition, but that achromatolysis 
means permanent damage to the neuron because it signifies 
destruction of the kinetoplasm. | } 

There are certain considerations, however, which suggest that 
the mechanism underlying the cardinal symptoms of this disease 
is an increase of synaptic resistance more or less throughout 
the nervous system. Let us examine each of these symptoms in 
turn: analgesia, hallucination and imperception. 

I have already remarked that repeated and multiple stimuli 
overcome the resistance which underlies the analgesia. The con- 
clusion from such experience is that this resistance is at the 
synapses, and not in the neurons; for there are no observations to 
show that a strong stimulus will overpower a block in a neuron 
more readily than a weak one. Indeed all the available evi- 
dence negatives such a suggestion and Sherrington’s experiments 
on the scratch reflex of the dog show that multiple subliminal 
stimuli will overcome synaptic resistance. 

Again, on p. 137 we came to the conclusion that one of the 
elements in the mechanism of hallucination is dissociation of the 
peripheral neurons from the central nervous system. This was 
how I put it some twenty years ago; I would now say that there is 
increased resistance at the synapses between the peripheral and 
more central neurons. 

Lastly, it occurred to me to try the effect of some drug which 
would diminish the resistance at the synapses in these cases. 
The drug which stands pre-eminent for such a purpose is 
strychnine, and I found that in several mild cases of this disorder 
Niv. of the liq. strychnine subcutaneously injected three times 
a day abolished the anesthesia and the hallucinations and 
rendered the patient’s perception perfectly clear in a most 
remarkable manner. In two or three cases this treatment 
proved the turning-point in the patient’s illness. 

The conclusion is that in acute confusional insanity there is 
an increase of the normal resistance at the synapses to the pas- 
sage of neurokyme. But the synapse is not a thing in itself; it 
is merely a site of contact between two neurons, and we can 
only suppose that any disturbance of its functions must be due to 
some affection of the neurons themselves. It may, therefore, quite 
well be that such observations are of purely academic interest. — 


ACUTE CONFUSIONAL INSANITY 397 


Treatment.—In the first instance cerebral activity must be 
reduced to a minimum and the supply of nutriment raised to 
a maximum. In other words, the patient must have plenty of 
rest and plenty of good nourishing food. 

Rest is to be obtained by keeping the patient in bed during the 
greater part of his illness. If he will not remain in bed, the habit 
of quietude may often be induced by a preliminary course of 
prolonged baths. 

It is usually necessary to resort to drugs to promote sleep and 
reduce motor excitement. For this purpose paraldehyde and 
amylene hydrate are the best, 14 drachms being administered 
night and morning (two or three tablets of dial serve the same 
purpose); these patients are especially liable to develop symp- 
toms of poisoning if they are treated with sulphonal. Hydro- 
bromide of hyoscine (z$5 grain) or liq. morphine bimeconatis 
(4 drachm) three times a day may also be found a useful sedative. 
It must be remembered that these cases are easily susceptible 
to fatigue long after the symptoms have apparently disappeared. 
It is therefore a great mistake to get the patient up too 
soon, for this may induce relapse. Most cases require, at 
the very least, two months’ continuous rest in bed. It 
need scarcely be insisted that restraint should be avoided, 
especially that most objectionable form, being “‘ held down ”’ by 
nurses. 

The diet should at first consist of 3 or 4 pints of milk, enriched 
by the addition of cream, and four to six eggs daily. The mode 
of preparation is, of course, to be varied. It may be as custard 
or hot bread-and-milk, or the milk may be flavoured with coffee 
or cocoa. Beef-tea and broth may be given between meals. 
In cases where the digestion is poor the food may be lightly 
peptonized. Tube-feeding is frequently necessary and should 
on no account be shirked. As the appetite improves solid food 
may be gradually substituted. Alcohol in the form of brandy, 
port or stout, according to the patient’s requirements, is a useful 
adjuvant. Apart from its stimulating properties it promotes 
sleep and improves the appetite. 

Iron in some form which does not disturb the digestion is 
indicated in nearly all cases; the scale preparations are probably 
the best for this purpose. Constipation should be combated 
by the judicious use of purgatives, and intercurrent symptoms 
treated on general medical principles, as they arise. In threat- 
ened collapse the physician should resort to copious intravenous 
injection of normal saline solution. 


398 MIND AND ITS DISORDERS 


Massage may be usefully employed for patients who are 
sufficiently restful to allow it and, when the general nutrition 
is thoroughly restored, a favourable termination can frequently 
be accelerated by the judicious use of such tonics as 
strychnine. | 


CHAPTER XV. 
ALCOHOLIC INSANITIES. 


Ir will not have escaped the reader that the description of acute 
confusional insanity is applicable to delirium tremens but, 
inasmuch as other varieties of alcoholic poisoning have to be 
recognized, it has been decided to consider this group as a 
separate chapter. It is not strictly correct, however, to regard 
alcoholic insanity as a distinct disease. 

Etiology.—The determining factors of alcoholic insanity are 
(1) The nature and quantity of the alcoholic beverage employed 
and (2) the character of the individual who drinks it. 

Several investigators have found degenerative changes in the 
cortical nerve-cells of animals to which large quantities of ethyl 
alcohol have been given. We must therefore hold this substance 
responsible in a large measure for the deleterious effects of alco- 
holic beverages on the nervous system. These effects appear 
to some extent to increase part passu with the degree of con- 
centration; hence we find that spirits are by far the most per- 
nicious form of alcoholic beverage. General experience, however, 
points to the conclusion that the higher alcohols and aldehydes 
which, according to certain revelations some years ago, are 
contained in many varieties of whisky and brandy, are much 
more poisonous than ethyl alcohol. It would be interesting 
to know if those degenerates who take their alcohol in the form 
of eau-de-Cologne, lavender-water, tooth-washes or spirit from 
the specimen jars of anatomical museums ultimately suffer from 
chronic alcoholic insanity; I have not heard of sucha case. The 
disease undoubtedly occurs in other than spirit-drinkers; but the 
other forms of alcoholic beverage, even when taken in large 
quantities, appear to be much less potent to produce insanity. 
Even our three-bottle ancestors, whose excesses are reported to 
have been very productive of gout, are not, so far as I am aware, 
said to have been especially liable to insanity. 

Although experience teaches that the daily ingestion of alcohol 
is conducive to general health and well-being, several German 
experimenters have found that increased motor excitability and 

399 


400 MIND AND ITS DISORDERS 


diminution of the mental powers are discoverable for some 
thirty-six hours after the ingestion of about two litres of German 
beer. The conclusion from such findings is that everybody who 
takes alcohol regularly with his meals is permanently under its 
influence. It therefore becomes somewhat difficult to decide 
what quantity of alcohol is to be called excessive. A person’s 
sensations may be quite unreliable, for some people can drink 
enormous quantities of alcohol for years without ever being, in 
the popular sense, the worse for drink. Yet the ultimate result 
is permanent damage to the nervous system. Such a person 
should ascertain how much alcohol his tissues are capable of 
oxidizing and make it a rule to keep within that quantity. If 
he drinks more than this, the excess is excreted and may be 
detected in the breath four or five hours after its ingestion. It 
has been demonstrated that alcohol is also excreted in the urine, 
sweat and bile and that it may be detected in the blood. As 
long ago as 1839 Percy demonstrated its existence in the ven- 
tricles of the brains of animals poisoned with alcohol and showed 
that the nervous tissues had a peculiar affinity for this drug. 
Most people are capable of oxidizing about 2 ounces of alcohol 
in the twenty-four hours; this quantity is contained in about 
4 ounces of brandy, whisky, rum, gin or liqueur; 10 ounces of 
port, sherry or Madeira; a pint of champagne, hock or claret 
or 2 pints of beer. It need scarcely be urged that, if these 
maximum quantities be taken, it is not desirable that they be 
taken at one sitting if it is intended that they should be oxidized 
and produce no pharmacological effect. Rivers and Webber 
have shown that doses of alcohol up to 20 c.c. (about 6 drachms) 
have no influence in increasing or diminishing muscular work. 

The brain of a normal person possesses the power of resisting 
the effect of a certain amount of alcohol, which is usually much 
more than that above mentioned and varies with different indi- 
viduals. If a larger amount than this be taken the result is 
physiological inebriation. In some individuals, however, the 
capacity of resistance to alcohol is very small indeed: with them 
the ingestion of very small quantities leads to pathological 
inebriation. 

An intolerance of alcohol may be congenital or acquired. It 
is congenital in persons with a neuropathic inheritance, especially 
in epileptics and patients who are subject to the intermittent 
and periodic forms of insanity or suffer from dementia przecox. 

It is acquired by many persons who have been subjected to the 
influence of prolonged fevers or sunstroke, have received at 


PHYSIOLOGICAL INEBRIATION 401 


some time a violent blow on the head or have been guilty of 
frequent alcoholic excesses in previous years. In this last case 
the result may be anaphylactic in origin. 


PHYSIOLOGICAL INEBRIATION. 


This condition is a passing disturbance of the physical and 
mental functions, induced by a poisonous dose of alcohol. At 
first there is an increase in the frequency of the pulse and respira- 
tion with general dilatation of the arterioles and consequent 
lowering of blood-pressure. This gives rise to a feeling of 
warmth and well-being. Muscular power is increased and the 
onset of muscular fatigue delayed, as shown by the ergograph. 
The imagination and flow of ideas are stimulated. 

On the other hand the faculty of volition is reduced, including 
the capacity for mental work, voluntary attention and the 
capacity for passing judgment in the course of an argument. 
The moral sense and the power of self-criticism are diminished. 
There is a tendency to the formation of illusions and a certain 
_ amount of imperception occurs. In the domain of vision this 
may be partly due to crossed diplopia. 

The emotional tone varies in different individuals. Most 
people are jovial, some are hilarious, others are depressed and 
perhaps tearful; some are arrogant and querulous, others again 
are suspicious or sentimental. 

Similarly the disorder of speech varies in different individuals. 
Some are garrulous and incoherent, others are dumb, and yet 
others eloquent. Articulation is difficult and indistinct. 

When the intoxication is more advanced the drunkard loses 
control of his limbs and staggers in his attempts to walk. The 
frequency of the pulse and respiration now become diminished. 
There is well-marked anesthesia, external impressions fail to 
reach the sensorium and the patient falls into a deep sleep or 
coma. Recovery usually takes place after several hours, leaving 
a sense of malaise with headache and loss of appetite. Death 
sometimes occurs from paralysis of the respiratory centre. 

To be “drunk in a public place’’, “drunk and incapable ”’ 
and “drunk while in charge of a motor-car’’ are indictable 
offences and recent arrests under the third category have raised 
the question of differential diagnosis on several occasions. It 
appears that quite a moderate dose of alcohol will render some 
persons unable to manage a motor-car and may thus cause them 
to be a public danger, especially those who already have some 

26 


402 MIND AND ITS DISORDERS 


organic affection of the nervous system or have previously suffered 
from neurosis, particularly war neurosis. For the public safety 
and for their own reputation it behoves such people to become 
teetotallers. The diagnosis depends upon the presence of several 
of the above-mentioned symptoms. There is no one pathog- 
nomonic sign of drunkenness, but any man in the street can © 
diagnose the malady, given a sufficient number of obvious signs. 

Treatment consists in washing out the stomach and adminis- 
tering a purge with sal volatile or hot coffee, perhaps reinforced 
with 5 grains of caffeine. Occasionally it becomes necessary to 
resort to artificial respiration. 


PATHOLOGICAL INEBRIATION. 


This disorder is usually caused by much smaller quantities 
of alcohol than are necessary to induce the condition above 
described; in some cases one or two glasses of beer are sufficient. 
It arises in patients with congenital or acquired neuropathic taint. 

The commonest form, mania a potu, is an attack of intense 
motor excitement. The patient appears. to be in a state of 
semiconsciousness and to have absolutely no control of his 
actions. In his violent fury he may attempt homicide or 
suicide, especially by precipitation. Indecent exposure, carnal 
assaults on women, incendiarism and thefts are common, the 
patient remembering little of such incidents on his recovery. 
There is usually some tremor of the hands and tongue and 
difficulty of articulation. The gait is uncertain and slightly 
reeling, but the patient is capable of steadying himself when he 
finds that this symptom is attracting attention. The knee-jerks 
are diminished. Recovery usually takes place in a couple of 
days without treatment. 

Tanzi mentions an apoplectic form which sometimes leads 
to coma and death. It would therefore be well to wash out 
the stomach should the patient be seen sufficiently early. 

Pathological inebriation occasionally resembles the physio- 
logical variety, the only difference consisting in the small quan- 
tity of alcohol which has induced the condition. Transient 
depression with suicidal tendency sometimes occurs. 


DELIRIUM TREMENS. 


Delirium tremens is an acute disorder resulting from chronic 
alcoholism. A single alcoholic bout will not produce delirium 
tremens unless the patient has been continuously under the 
influence of alcoho] for at least some weeks previously. 


DELIRIUM TREMENS 403 


An attack may be precipitated by any kind of shock, especially 
physical injury, such as a fracture or a surgical operation, and 
acute fever, such as influenza, pneumonia or typhoid. In the 
treatment of these conditions the patient is generally put to bed 
and deprived of his usual excessive quantity of alcohol; it is 
then found that delirium tremens develops. This suggests that 
the disorder is due, not to alcohol, but to the sudden deprivation 
of alcohol. This doctrine also receives support from the usual 
history that the patient has taken no alcohol for several days 
previous to his illness, but this might be explained by the fact 
that one of the earliest symptoms is a dislike for stimulants. 
We learn from the authorities of prisons that suddenly enforced 
abstinence does not invariably in itself induce an attack, even 
in the worst drunkards. Moreover, we are bound to admit that 
we see many patients who have drunk hard right up to the time 
when they come under observation. Loss of appetite for food 
is a feature which has given rise to a probably mistaken notion 
that failure to take nourishment is an etiological factor, but this 
is one of the early symptoms of the disease. 

It is probable that delirium tremens is not due to the direct 
action of alcohol, but rather to a secondary auto-intoxication; 
otherwise the condition should pass off within forty-eight hours 
of the last bout, by which time almost every vestige should 
be eliminated; whereas clinical experience teaches that the 
disease lasts from four days to three weeks or more. It’ is 
now well established that the introduction of any poison into 
the system stimulates the tissues to throw out defensive substances 
of various kinds and it seems likely that, in the case of chronic 
alcoholism, these would-be defensive substances, being produced 
in excess, are at least partly the cause of delirium tremens. 

Another etiological factor is the predisposition of the individual 
to this particular form of alcoholic insanity, since we find that 
delirium tremens is liable to occur several times in the same person. 

Onset.—The first indications make their appearance in the 
night. The patient is restless and sleepless. What snatches of 
sleep he can get are disturbed by horrifying dreams. By day 
he is restless, suspicious, irritable and timid. 

Physical Signs.—The general aspect of the patient is charac- 
teristic. His face is flushed, his conjunctive suffused and his 
skin bathed in sweat. During the first few days there may be 
a rise of temperature: this is not above 100° F. as a rule, but 
I have seer it as high as 104° F. 

The flow of saliva is increased, the tongue is therefore moist 


404 MIND AND ITS DISORDERS 


and but slightly furred. The appetite is poor and the patient 
may absolutely refuse food so that he has to be tube-fed; there 
is even a revulsion from alcohol. Constipation is the rule. 

The pulse is frequent, soft and full in the early stages; later 
it tends to become small and feeble. The respirations are deep — 
and slightly increased in frequency; the breath has a heavy, 
offensive odour. . . 

The urine is scanty and high-coloured and its specific gravity 
is raised; it frequently contains albumin and casts. The blood 
shows a general leucocytosis with diminution of the eosinophiles. 

The pupils are at first contracted, but they usually become 
dilated as the disease progresses. There is general motor weak- 
ness associated with tremor. This tremor is an exaggeration of 
that of the habitual drunkard. It is said to occur first in the 
feet. It is rather coarse, increases on movement and affects the 
fingers, lips and tongue most; but in a severe case it may he 
detected in any part of the body by placing one’s hand there. 
The hands and fingers are in constant movement, a symptom 
which may be taken to indicate irritation of the cortex by 
toxins in the blood. The knee-jerks are usually diminished, in 
some cases they are exaggerated and rectus clonus occurs. The 
superficial reflexes are diminished or absent. 

Mental Symptoms.—Many authors state that there is a general 
hyperesthesia during the early stages. This may be so; but 
later in the disease, especially in the more protracted cases which 
are seen in mental hospitals, there is peripheral analgesia and con- 
traction of the visual fields. 

The most striking disturbances are in the domain of percep- 
tion. Hallucinations, especially visual, dominate the clinical 
picture. The patients see enormous spiders, rats, snakes, 
vultures, mannikins with ugly faces, grimacing devils with 
pitchforks and all manner of strange beasts, terrifying and 
grotesque in their hideousness. These hallucinatory objects are 
usually slate-blue in colour, hence the popular name “ blue 
devils’. A piece of red glass placed before the patient’s eyes 
does not alter the colour of these images. The hallucinations 
of hearing are also of a terrifying nature, such as revolver shots, 
the clatter of engines of torture and voices saying “‘ Kill him !”’ 
“Let us skin him!” “Murderer!” etc. Cutaneous hallucinations 
are in keeping; the patient feels the sting of the serpent’s fang, the 
dog’s bite, the stroke of the knife, stabs and sensations of burning. 

Hallucinations are easily induced in such patients. If you 
point to the floor and say “‘ What is that ?’’ he will answer “ A 


DELIRIUM TREMENS 405 


snake ’’, “A dog”’, “ A flower ’’, according to the nature of the 
image induced. Pressure on the closed eyelids will evoke moving 
pictures. If this be done and the patient asked what he sees, he 
will answer somewhat in this fashion: ‘‘I see a horse. Here 
comes a man; he is mounting the horse; now he is riding towards 
me’ etc. Or if you say to the patient, ‘“‘ Listen! what is that 
noise ?”’ he will answer “Soldiers ’’, ‘‘ Music’, ‘‘ The dog bark- 
ing ’’, the answer varying, of course, with the nature of the 
hallucination. Hallucinations of other senses may be similarly 
suggested. This feature is almost peculiar to delirium tremens; 
but I have observed it in a few other cases in which hallucinations 
were a prominent symptom. 

In spite of the extraordinary grotesqueness of many of the 
hallucinations the patient invariably accepts them as real. He 
is unable to recognize their true nature. Yet in the midst of 
the delirium a sharp word will bring him to his senses and he 
will converse rationally for a few moments. 

Imperception is another prominent symptom. There is 
partial psychical (not retinal) colour-blindness, so that the 
patient confuses greens and blues, especially yellowish and 
greenish blues. Objects cannot be recognized, at least if they 
are at all out of the ordinary, and if the patient be shown a 
simple picture he is unable to tell what it portrays. Similarly 
he is unable to understand simple commands if they be uttered 
in a monotone without his being shown what to do. If for 
example you say to him “ Put your left little finger on your nose ’’, 
he is utterly confused as to your meaning. Motor and agnostic 
apraxia are present in all severe cases. 

Disorientation is constant. The patient may look round his room, 
perhaps the padded room of an asylum, and out on the asylum 
grounds and yet believe himself to be inhisown home. He cannot 
tell the time of day, the date, month or even in some cases the year. 

Except for the distracting effect of hallucinations the flow of 
ideas is coherent and obeys the ordinary rules of association. 

The memory for recent events is practically nil; the events of 
former years are well remembered. 

The general emotional tone dependent to a large extent on 
the tremor is one of timidity, anxiety and fear. Emotional 
reaction is good but dominated by hallucinations. In those 
rare cases in which the hallucinations are of a pleasant nature 
the patients may be more or less cheerful. 

At the height of the disease the instinctive motor system 
dominates action and volition proper is in abeyance. Actions 


406 MIND AND ITS DISORDERS 


tend to be impulsive, are frequently of a violent character and 
are mostly initiated by hallucinations. Homicidal and suicidal 
impulses sometimes occur. 

Actions which have become automatic are also in evidence; 


hence occupation delirium is almost a constant feature. The — 


butcher busies himself in hanging up carcasses, the carpenter saws 
imaginary pieces of wood, the small shopkeeper spends his time 
putting up and taking down the shutters of his shop and so on. 

Attention can always be reflexly aroused with a little trouble, 
e.g., by shaking the patient and speaking sharply to him; but 
active voluntary attention does not occur during the height of 
the disorder. 

Except for occasional incoherence and the erroneous choice 
of words (paraphasia) speech is normal. Articulation, on the 
other hand, is usually tremulous and blurred, the greatest diff- 
culty being with the consonants. 

Insomnia is absolute, at least in those cases (the majority) which 
last three or four days. The disease terminates, however, in a pro- 
found sleep. Inthe prolonged cases sleep returns more gradually. 

The patient’s subsequent recollection of the various details of 
his illness is very imperfect. This characteristic of the disease 
probably accounts for the fact that such an experience has no 
deterring effect on the chronic drunkard. The illness being over 
he soon lapses into his old habits. In all too many cases the 
disorder again and again recurs. 

Prognosis.—Nearly all the cases make a complete and rapid 
recovery. In a certain number, however, it is found, on re- 
covery from the acute condition, that the patient is an alcoholic 
dement or that there is a substratum of chronic mania or some 
of the other alcoholic disorders hereinafter described. The 
disease terminates fatally in about 5 per cent. of the cases, 
usually from cardiac failure. This result is to be feared when 
the sphygmographic tracing shows an “irregularly undulating ”’ 
character (Anstie). The prognosis should be guarded when a 
large amount of albumin is present in the*urine and especially 
when the daily amount of that secretion begins to fall. In a few 
cases death occurs from convulsions. 

Treatment.—Delirium tremens should be treated in a more 
or less darkened room in which there is a plentiful supply of 
fresh air. If these conditions can be obtained in a padded room, 
so much the better. The patient should be persuaded to remain 
in bed; but it is better to allow a certain amount of restlessness 
than to exhaust him by constant struggling. 


DELIRIUM TREMENS 407 


Plenty of nourishment should be administered in small doses 
at frequent intervals. Bread-and-milk or milk alone is the best 
form. It is better to avoid soups, beef-tea and mince, lest such 
articles of diet should throw too much strain on the kidneys. 
Bread-and-butter, vegetables and fruit are permissible if the 
patient can be induced to take them. If, as seems probable, 
delirium tremens is caused by anti-alcohols, physiological anti- 
dotes to alcohol produced by the tissues, it would appear to be 
reasonable treatment to neutralize them by allowing a little 
alcohol to the patient and this idea is supported by practical 
experience. It is found that the disease is mitigated and indeed 
that life is sometimes saved by giving two or three ounces of 
brandy daily at first and then gradually reducing the amount so 
that the patient is taking no alcohol at all by the sixth day. 
The tapering would, of course, be more rapid than this in mild 
cases. Some authorities are of the opinion that this administra- 
tion of alcohol prolongs the course of the disease; I do not agree. 

The only medicines which seem to be required are hypnotics; 
but these patients are so remarkably tolerant of hypnotics that 
only the most alarming doses are at all effectual. Anstie used 
to give as much as 2 drachms of chloral hydrate in the twenty- 
four hours. It seems to the author that three nights of insomnia 
are likely to prove much less dangerous to the patient’s life than 
such enormous doses of a cardiac depressant. 

If, however, a hypnotic appears to be imperative, paraldehyde 
or amylene hydrate in doses of 14 drachms or sulphonal in 
30-grain doses nightly are to be preferred. 

Should the secretion of urine begin to fail infusion of digitalis 
in 4-ounce doses every three hours is indicated. Some of the 
older physicians used to regard this drug as a specific for delirium 
tremens. 

In spite of the most careful treatment we occasionally en- 
counter cases in which collapse threatens about the third day, 
collapse which appears to be due to the sudden deprivation of 
alcohol. In such circumstances it becomes necessary to allow 
4 ounces of brandy daily for a short time. The effect is nothing 
short of marvellous. Here indeed we have a condition in which 
the life of many a patient may be saved by means of “a hair of 
the dog that bit him ”’. 

Chloral Delirium Tremens.—Delirium tremens is occasionally 
caused by the abuse of chloral hydrate. At the present day 
when there is such a multiplicity of hypnotics accessible to the 
general public, chloral delirium tremens appears to be much less 


408 MIND AND ITS DISORDERS 


frequent than it was twenty years ago when the number of 
known hypnotics was more limited. I have never seen a case. 
In its clinical aspect the disease differs in no essential par- 
ticulars from the alcoholic form. It is said that the tremor | 
caused by chloral is finer than that caused by alcohol and that 
the odour of the breath at the onset of the disease is that of 
chloroform. It follows that the physician must usually rely 
on the previous history of the patient in order to make a correct » 
diagnosis. 


POLYNEURITIC INSANITY. 


KoORSSAKOW’S SYNDROME. 


I place the description of polyneuritic insanity among the 
alcoholic insanities because alcohol is the most common cause 
of the disorder. Korssakow obtained. an alcoholic history in 
three-fifths of his cases. Other causes are phthisis, influenza, 
septic infection, diabetes and chronic poisoning by arsenic, lead, 
mercury or carbon bisulphide. Dupré reports that he has known 
the disease to be caused by intensive mercurialization for syphilis. 

The disease occurs more frequently in women than in men 
and usually in adult life. The earliest case which I have observed 
was that of a girl aged fourteen who developed the disease 
from taking large doses of arsenic for chorea and I have seen two 
similar cases under twenty years of age. Neuropathic heredity 
is fairly frequent. 

The disease, as its name denotes, is a mental disorder asso- 
ciated with peripheral neuritis. While the insanity is charac- 
teristic, the neuritis differs in no way from neuritis unaccompanied 
by mental symptoms. The muscles of the limbs are tender 
while the skin over them is anesthetic or hyperesthetic. There 
is either inco-ordination or paralysis of movement. The tendon 
reflexes are absent or, less frequently, exaggerated and there 
may be some nutritional disturbance such as “ glossy skin ”’ or 
splitting of the nails. In the alcoholic cases nystagmus is 
common and central scotomata may occur. For a fuller account 
of neuritis the reader must refer to works on general medicine. 
The appetite is poor and the patient loses weight, this loss being 
partly due to muscular atrophy consequent on the neuritis. 

Mental Symptoms.—The mental symptoms appear somewhat 
suddenly, sometimes with an attack of delirium tremens. There 
are commonly a few hallucinations of vision during the early 
stages of the disease, but they are not a prominent feature in 
the clinical picture. Imperception is well marked, especially in 


POLYNEURITIC INSANITY 409 


the domain of vision; the patients may not be able to recognize 
familiar objects and they cannot always take in a situation por- 
trayed in a drawing. They usually mistake identities and are 
disorientated in time and place. 

There is commonly some predominant emotional tone which 
varies from patient to patient, such as depression, hilarity, 
anger, anxiety, or surprise. Nevertheless emotional reaction is 
normal or perhaps exaggerated, the patient weeping or crying 
on trivial provocation. Instinctive attention is normal, but 
voluntary attention poor. In spite of a considerable degree of 
mental confusion, instinct and volition are but little affected. 

Disturbances of memory are the most pronounced feature of 
the disease. The memory of incidents which occurred prior to 
the illness is fairly good, but the patient is unable to store up 
new impressions (anterograde amnesia). There is consequently 
profound loss of memory for recent events. 

It is in this disease that so-called faramnesia occurs most 
characteristically—illusions of memory and illusions of recogni- 
tion. The most common illusion of memory is that the patient 
believes that he has been out for a walk when he has not left 
his bed or that he has just received a visit from some relation 
when nothing of the kind has occurred. The most common 
illusion of recognition is that he recognizes his present environ- 
ment as having been previously experienced. He will say that 
he has been in the hospital before when it can be proved that he 
has not; or perhaps he erroneously recognizes some of the atten- 
dants as old acquaintances. 

It would appear from the following incident that illusions 
of memory may sometimes be suggested to these patients. One 
morning I asked the patient B. whether he had been out for 
a walk. He told me he had been up the Kennington Road with 
W., another patient suffering from polyneuritic psychosis, to 
pawn his watch. Knowing well that neither patient had been 
outside the grounds I confronted B. with W. and asked “‘ Have you 
been out with B. this morning ?’’ Tomy astonishment, W. replied 
“Yes, doctor: I went with him up the Kennington Road to pawn 
his watch’”’. There was no attempt to deceive on the part of these 
patients; both really believed that the incident had taken place. 

Suggestibility in these cases is also shown by the readiness 
with which they will believe the most improbable tales. I 
remember a patient at Bethlem to whom I remarked “ I under- 
stand that you had to row across the lake to the funeral yester- 
day’’. He accepted the suggestion and even gave me details. 


410 MIND AND ITS DISORDERS 


As in all alcoholics there is poverty of judgment and of the critical 
faculty. Nevertheless fixed delusions are rare. 

Speech and articulation are usually unaffected. 

The patient is sleepless for a week or two at the beginning of 
the disease, but unless the pains in the limbs are troublesome 
the insomnia soon passes off. 

Clinical Varieties.—The clinical picture varies somewhat with 
the prominence of this or that symptom. The French school - 
recognizes amnesic, confusional, delusional, anxious and demented 
forms of the disease. Such a classification appears to be un- 
necessary. On the other hand it is important to recognize that 
the disorder above described sometimes occurs without any 
clinical signs or symptoms of peripheral neuritis. 

Prognosis.—Kecovery generally takes place in six to twelve 
months, but the disease usually leaves a certain amount of 
mental enfeeblement, sometimes profound enough to necessitate 
permanent care in an asylum. JDeath from cardiac failure 
occurs In a few cases. 

Morbid Anatomy.—Patients who have died of this disease 
show fatty degeneration of the liver, kidneysand heart. There 
is usually some cedema of the meninges and the cerebral cortex 
is thinner than natural; otherwise macroscopic examination of 
the nervous system reveals nothing abnormal. 

In those cases in which there is a certainamount of chronic 
meningitis, mild lymphocytosis may be detected in the cerebro- 
spinal fluid. This may be ascertained by means of a lumbar 
puncture during life. 

Microscopical examination of the cortex cerebri reveals atrophy 
of the tangential fibres and degeneration of nerve-cells, which 
is best seen in the giant-cells of Betz. The degeneration is 
rather characteristic; the cell-body is swollen, the nucleus 
swollen and eccentric in position and there is perinuclear chroma- 
tolysis. Subsequently, the nucleus becomes adherent to the cell- 
wall, shrinks and disappears; then chromatolysis takes place in 
the periphery of the cell-body. Similar changes may be observed 
in the large motor cells of the anterior horns of the spinal cord. 
This form of degeneration is that which takes place when the 
axis-cylinder of a neuron has been damaged (réaction a distance). 

From these observations it is to be concluded that the brunt 
of the battle with the toxic agent which induces the disease is 
borne by the nerve-fibres of both the peripheral and central 
parts of the nervous system and that the cell changes are 
secondary to the fibre changes. 


Hic: Waa. BrEtTz CELL IN A STATE OF AXONAL REACTION 
(REACTION A DISTANCE) SUCH AS IS PRODUCED BY SEVER- 
ANCE OF OR INJURY TO THE AXON. 


In this case there is advanced chromatolysis beginning 
in the central part of the cell and spreading outwards, and 
the nucleus is displaced and shrunken. It is often impossible 
to differentiate early stages of this change from the immature 
form represented in Fig. 59. [Negative kindly lent by Dr. 
John Turner of Brentwood Asylum. ] 


To face p. 410 


F me a 7 | . a 
UH ‘ | | ‘ 7 = 
- : : i 7 - . a 
: ¥ 
‘ 


14> 


ALCOHOLIC PSEUDOPARESIS A4II 


In some subjects the peripheral nerves are less resistant than 
the cortical fibres to the action of a toxin and multiple neuritis 
occurs; in others the cortical fibres and peripheral nerves are 
equally vulnerable and we have a typical case of the polyneuritic 
psychosis; in a third class the cortical fibres are less resistant 
than the peripheral nerves with the result that the mental dis- 
order occurs but is unassociated with multiple neuritis. 

Treatment consists of prolonged rest in bed and improvement 
of the general nutrition by means of a plain liberal diet with 
plenty of milk. Alcohol and other drugs which are apt to induce 
neuritis should be withheld. 

If there is severe pain in the limbs it may be mitigated by 
phenacetin or antifebrin; a water-bed is often desirable. The 
nutrition of the wasted muscles may be maintained by daily use 
of the constant current. When all pain and tenderness have 
disappeared massage is useful and the patient may be permitted 
to get up for the greater part of the dav. 


SUBACUTE ALCOHOLIC INSANITY. 
ALCOHOLIC PSEUDOPARESIS, 

This is a subacute form of alcoholic insanity induced by 
chronic alcoholism. The disorder owes its name to the resem- 
blance which, in its earlier stages, it bears to general paralysis. 

Epileptic and epileptiform convulsions may occur. Pseudo- 
paresis is not, however, the only form of alcoholic insanity 
associated with convulsions. Isolated attacks may happen to 
a chronic alcoholic after a single debauch: they may usher in 
an attack of delirium tremens or coma during the course of that 
disease or they may be observed during the early stages of the 
polyneuritic psychosis. Convulsions are especially mentioned 
in this connection, because they, among other symptoms, are 
liable to mislead an unwary practitioner into supposing that he 
has to deal with a case of general paralysis instead of one of 
_ subacute alcoholic insanity. 

As in general paralysis there is well-marked tremor of the 
face, tongue and hands, but the tremor has different charac- 
teristics in the two conditions. Alcoholic tremor tends to affect 
the upper part of the face (orbiculares palpebrarum) rather 
than the lower as in general paralysis: the lingual tremor is a 
rippling on the surface, not, as a rule, an ataxic trombone 
movement as in general paralysis; and, while the tremor of the 
fingers is coarser in alcoholism, the alcoholic is more capable of 
steadying the tremor than the general paralytic. 


412 MIND AND ITS DISORDERS 


The alcoholic is more ataxic than the paralytic in his move- 
ments: the former totters when he walks, the latter shuffles. 
The pupillary light-reflex is retained in pseudoparesis except in 
a few syphilitic cases, but the pupils may be unequal in size. 
Contraction of the visual field is liable to be more marked in 
pseudoparesis than in general paralysis and there may be central 
scotomata. 

The knee-jerk is usually exaggerated, but not “ floppy ”’ as in 
general paralysis. In some cases associated with neuritis the 
knee-jerk may be absent. The physician is then called upon to 
make a differential diagnosis between peripheral neuritis and 
tabes dorsalis. 

In some of the neuritic cases there may be anesthesia of the 
hands and feet. 


Ve. Yarc Jen Ut ble 
(pth, dba Shige ‘ Myplb 
Monging ee 


Fic. 65.—WRITING IN SUBACUTE ALCOHOLIC INSANITY. 


The patient was asked to write ‘‘ Now is the time for all good men to 
rally round the cause ’”’; then, “‘ She sells sea-shells and shaving-soap.” 


Mental Symptoms.—These develop much more rapidly in 
pseudoparesis than in general paralysis. The patient is more 
confused in the early stages; he is disorientated in place and 
time and there is general imperception. 

Hallucinations of vision occur and are liable to take the shape 
of animals; hallucinations of the other senses are not common. 

There is confusion of ideas; judgment and reasoning are 
almost in abeyance. Expansive delusions occur as in general 
paralysis and there may be delusions of persecution. 

At first the instincts and emotions are deficient and the patient 
may be wet and dirty. Later, as he improves, he becomes 
excessively emotional. He is incapable of sustained attention 
and instinctive attention is reduced to a minimum. There is 


ALCOHOLIC PSEUDOPARESIS 4T3 


great disturbance of memory, the amnesia being much more 
profound than in an early case of general paralysis. 

Incoherence of speech is the rule. Articulation is difficult, 
chiefly on account of the patient’s tremulous condition; but 
there is not the same tendency to elide or repeat syllables and 
words as there is in general paralysis. Similarly writing is 
difficult on account of the hand tremor and general confusion. 

Insomnia is well marked after the patient has slept off his 
last alcoholic bout, whereas the general paralytic sleeps fairly 
well when first he comes under observation. 

Course and Prognosis.—The most striking difference of all 
between pseudoparesis and general paralysis is that recovery 
from the former condition is usually complete within two or 
three months. It is true that there may be a certain amount 
of residual dementia, but it is not progressive. Death occurs in 
a few cases from cardiac failure or convulsive seizures. 

The morbid anatomy of the condition is that of chronic alco- 
holism. To a certain extent it resembles that of general para- 
lysis; but there is less involvement of the neuroglial elements, 
decortication does not occur on stripping the pia-arachnoid from 
the cerebrum and granulation of the ventricles is uncommon. 

Treatment is carried out on general lines, viz., removal of the 
cause of the disease, maintenance of nutrition, relief of insomnia 
and prevention of self-injury. Asa general rule alcohol is with- 
held; but, should collapse threaten during the earlier stages of 
the disease, alcohol will probably save the patient’s life. 


CHRONIC HALLUCINATORY INSANITY. 


This form of alcoholic insanity is characterized by delusions 
of persecution based upon persistent hallucinations, especially 
of hearing and cutaneous sensation. 

Physical Signs.—In this disease the physical signs referable to 
the nervous system are practically nil. There may be slight tremor 
of the fingers and tongue and there is commonly exaggeration of 
the deep reflexes when the patient first comes under observation: 
even these signs disappear as the disease becomes established. 

There is usually loss of appetite on account of an acid dyspepsia 
and the bowels are constipated. There may be some enlarge- 
ment of the liver and albumin may be present in the urine but 
such changes are infrequent. 

Mental Symptoms.—On examination sensation and perception 
appear to be normal and the patients can appreciate the nature 


414 MIND AND ITS DISORDERS 


of their environment. At first they complain of headache and 
general malaise; these symptoms soon disappear with improve- 
ment of the general nutrition. 


The hallucinations occur at first during the night, subse-- 


quently during the day as well; gradually they dominate the 
whole mental life of the patient. He hears abusive, threaten- 
ing and mocking voices using disgusting and often obscene 


language. There seems to be a special tendency for these © 


hallucinatory remarks to have reference to sexual matters; the 
patient is told that he is impotent, that his wife is unfaithful 
and he is accused of unnatural sexual offences. He is threatened 
with all sorts of tortures. The voices are commonly referred 
to the ceiling, floor or walls; hence he believes that there are 
men on the roof, telephones in the walls and electric wires under 
the floor. Strange cutaneous sensations are similarly ascribed 
to some form of unseen agency. The patients are mesmerized, 
electrified by wireless telegraphy or X-rayed. Neologisms are 
commonly employed in this condition to explain the unusual sen- 
sations. One patient was “ petered in a hodge-podge ’’, another 
was persecuted by “the teleform switchback confederation of 
blacklegs ”’. 

Hallucinations of smell occur and give rise to the delusion 
that poisonous gases are instilled into the dormitory; hallucina- 
tions of taste similarly induce ideas of poison. 

Apart from the hallucinations the patient is capable of main- 
taining a coherent train of thought, and judgment is fairly good. 
He has, however, no insight into his mental condition; he accepts 
his hallucinations and is full of delusions of persecution. A few 
develop expansive delusions, a sure sign of intellectual ruin. 

The prevailing emotional tone is one of anxiety and quarrel- 
someness. The patients are difficult to get on with and are 
apt to limit their remarks to the doctor to monosyllables. 
Emotional reaction is good. 

Instinctive and volitional action are normal but dominated 
to a large extent by hallucinations. One patient used to wear a 
wet handkerchief on her head to ward off the electricity, another 
set “‘ booby-traps’’ at night to catch her persecutors, another 
filled the keyholes with paper to keep out noxious gases; others 
again perform grotesque actions to counteract the evil influences ; 
one patient, for example, would vigorously turn an imaginary 
handle in his heel whenever he had cutaneous pricking sensa- 
tions, as if to wind himself up. 

The patients are clean and tidy; they look after themselves 


ALCOHOLIC PARANOIA AI5 


and under supervision are capable of useful occupation. Speech 
is coherent, articulation clear and writing unaltered. Sleep is 
fairly good, but liable to be disturbed by hallucinations. 

Prognosis.—The disease almost invariably runs a chronic 
course. During the first two or three years the hallucinations 
tend to become less frequent and the patient passes into a 
condition of mild dementia. A few cases recover sufficiently to 
be able to return home. 

So far as I am aware, the morbid anatomy of this condition 
has not been investigated. The cases bear a remarkable re- 
semblance to dementia preecox, and we may safely say that the 
reason why chronic alcoholism produces this variety of disease in 
these particular patients is that deep down their psychical make-up 
is that of the dementia pracox patient. 

Treatment consists of the total withdrawal of alcohol, im- 
provement of the general nutrition and, in the majority of cases, 
permanent care in an asylum. 


ALCOHOLIC PARANOIA. 


This is a rare disease. It is a form of chronic delusional 
insanity in which hallucinations are absent or infrequent and 
play an unimportant réle. Probably it is true paranoia modified 
by the effects of alcohol. It usually begins about middle life 
and occurs more frequently in men than in women. 

Physical Signs.—When the patient first comes under observa- 
tion there are the usual signs of chronic alcoholism such as 
tremor of the hands and tongue, digestive troubles and exaggera- 
tion of the deep reflexes. These signs soon pass off with the 
withdrawal of alcohol. After a month or so there is complete 
absence of physical signs. 

Mental Symptoms.—Sensation and perception are usually 
normal. During the early stages there may be a few hallucina- 
tions. Ideation is normal; the patients are capable of initiating 
and maintaining an ordinary train of thought and their memory 
is fairly good for both recent and remote events. 

Disturbance of judgment is the essential feature of the disease, 
the patient seeing hidden meanings in the most commonplace 
incidents. As a rule, the erroneous judgments have reference 
to his wife’s fidelity. He sees evidence of her infidelity in the 
fact that she bows to an old acquaintance in the street, that 
some man unknown to him hurries past the window, that his 
wife is not prepared for his return from the office an hour earlier 


416 MIND AND ITS DISORDERS 


than usual or that the cushions on the sofa are not in their usual 
positions. 

If the disease is ushered in by an attack of delirium tremens, 
he may ascribe the illness not to his admitted alcoholic excesses, 
but to drugs introduced into his whisky by his wife. 

I have met with one case of religious paranoia due to alcohol. 
The patient was “converted” by a Salvation Army girl, took — 
to preaching and ultimately, by the help of hidden meanings 
in certain passages of Scripture, believed himself to be the re- 
incarnation of the prophet Jeremiah. He regarded the corona- 
tion stone in Westminster Abbey as God and as the stone on 
which Jacob rested his head. He believed England to be the 
land of Canaan, the Ark of the Covenant to be buried under a 
mound in Camberwell House, the grave of Eve to be situated 
in the grounds of Bethlem Hospital, and other absurdities. At 
the onset of the disease he had a few hallucinations, heard the 
voice of God and had visions of heaven. 

The patients are capable of sustained attention. Emotional 
and instinctive reaction are normal. 

A jealous patient is liable to commit violent assaults on his 
wife and her supposed lovers; otherwise his actions are normal. 
Speech and writing are normal and the patients are capable of 
useful employment in an asylum. 

Diagnosis.—The disease is distinguished from true paranoia 
by its rapidity of onset and absence of system in the delusional 
state. 

Prognosis.—The disease is incurable but not progressive. A 
certain amount of improvement sometimes takes place in an 
institution, but relapse occurs if the patient returns to his own 
home. 

The morbid anatomy of the condition has not been recorded. 

Treatment consists of total abstinence from alcohol and per- 
manent care in an asylum. 


ALCOHOLIC DEMENTIA. 


The natural termination of alcoholism is dementia. This may 
develop insidiously without the patient having an attack of 
acute insanity or it may be a sequel to some of the disorders 
above described. 

Symptoms.—Loss of sensation, when present, occurs on the 
backs of the fingers; it is seldom more extensive. Hallucina- 
tions and illusions are uncommon. Perception is good unless 


ALCOHOLIC DEMENTIA AI7 


the prolonged abuse of alcohol has resulted in severe degenera- 
tion of the cerebral arteries. 

The patients are irritable and difficult to get on with; they 
are consequently very annoying to others. This applies equally 
to cases of chronic mania resulting from alcoholism. 

Loss of memory is a constant symptom and may be so pro- 
found that the patient cannot remember what he has been told 
a few seconds previously. I have known a patient, who had 
been in the same ward for twelve months, ask an attendant 
for the lavatory as if he had only just entered the hospital. 
On being directed a distance of some twenty yards he would set 
out, forget the direction, return to another attendant and rail 
at him for not having directed him properly. 

There is poverty of ideation, falsification of judgment and 
warping of the reasoning faculties. Sometimes the patients 
express delusions of grandeur or write cheques for enormous 
sums of money. 

In the earlier stages the animal instincts are allowed full 
play owing to loss of voluntary control; in more advanced cases 
instinct is lost after the manner described on p. 157. 

In some cases the disease may be arrested by the withdrawal 
of alcohol; but there is no hope of improvement in the patient’s 
condition. In other cases the disease is progressive, leading 
to total obliteration of the mental faculties as well as to such 
motor weakness that the patient is unable to stand. Further 
he may be wet and dirty, liable to develop bedsores and require 
as much attention as a general paralytic; but the absence of 
physical signs of that disease and the general history of the case 
will prevent erroneous diagnosis. 

Morbid Anatomy.—In one case of this kind which I was able 
to examine post mortem, there was cedema and thickening of 
the meninges which stripped with abnormal readiness from the 
cortex. The cortex was thinner than natural and there was 
atrophy of the tangential fibres. Neuronal degeneration ex- 
tended to all parts of the cortex, the most striking feature being 
an almost complete absence of chromatoplasm from the cell- 
bodies. In the few cells in which chromatoplasm still remained 
it consisted of a very fine dust. 

It is noteworthy that it is extremely rare for cirrhosis of the 
liver to be found in patients who have come under observation 
for an alcoholic affection of the nervous system and, conversely, 
that alcoholic insanity and neuritis are very rarely found in 


patients who present themselves clinically for cirrhosis of the liver. 
27 


418 MIND AND ITS DISORDERS 


Treatment consists of permanent care in an asylum, mental 
hospital or private house where there is no possibility of access 
to alcohol. 

General Remarks on the Alcoholic Insanities.—Physiological 
and pathological inebriation, delirium tremens, polyneuritic 
insanity and perhaps pseudoparesis are clearly of a toxic nature; 
but the other varieties of so-called alcoholic insanity present — 
none of the features of an acute toxic confusional insanity. In 
the latter varieties we find that we are dealing with psychotic 
states resembling dementia precox, paraphrenia and paranoia. 
Indeed they really belong there and should not properly be 
included in this chapter. The only reason why they are placed 
here is that alcohol appears to have played the réle of weakening 
preconscious repressing forces and thus allowed the unconscious 
to assert itself. In other words the patients were latent cases 
of dementia precox or paranoia, which might have remained 
latent, at least for a longer period, had it not been for their 
seeking a solution of their unrecognized conflicts by taking large 
quantities of alcohol. 

In fine, alcohol is a psychological necessity for some people. 
They have terribly serious unconscious mental conflicts which 
can only be solved v4 alcohol or vid psychosis. Some seek the 
solution of their conflicts in both ways, as we have seen in this 
chapter. Such facts as these will have to be recognized by 
politicians, ministers of religion and other social workers before 
they can hope to diminish alcoholism and other drug habits 
without detriment to the community. Indeed I am not at all 
sure that the alcoholic restriction recommended for some of the 
maladies discussed in this chapter is ideal treatment. In practice 
it may sometimes be advisable to allow alcohol to an alcoholic 
just as we allow some epileptics to have their fits and make no 
attempt to diminish them with medicines. 


CHAPTER XVI. 


MENTAL DISORDERS ASSOCIATED WITH PRIMARY 
DISEASE OF THE ENDOCRINE ORGANS. 


ALTHOUGH these disorders are toxzemic in origin like the last 
group the symptom-complex is usually dissimilar. They there- 
fore require separate consideration. 

The mental disorders here discussed are those which arise in 
association with primary diseases of the thyroid, pituitary and 
pineal bodies, the sex glands and the adrenals. Of these only 
the thyroigenous insanities have hitherto received much atten- 
tion, mainly because others are apparently of rare occurrence. 
Moreover, the above-mentioned are not the only endocrine organs. 
There are also the parathyroids, the thymus, the pancreas and 
others; but I have not met with instances of mental disorder 
originating directly from disease of these bodies, other than 
cases of general exhaustion. 

Although there is an accumulation of evidence that there is 
an active process of atrophy in the genital glands in cases of 
dementia preecox and some authorities* have found the Abder- 
halden reaction to be positive to adrenal tissue in all their ex- 
amined cases (sixty-nine) of epilepsy, dementia precox and 
epilepsy are not included in this group because they are not 
related by heredity to diseases of the genital and adrenal glands, 
but to mental or cerebral maladies. For this reason I think 
that affections of the genital and adrenal glands in these maladies 
are to be regarded as secondary to the cerebral disorder. 


TOR UERY RO ED: 
MyxXCEpDEMA. 


Myxcedema or hypothyroidism is a somewhat rare disease, 
the essential pathological feature of which is diminution of the 
internal secretion of the thyroid gland. In the large majority 
of cases this is due to simple atrophy and.sclerosis of the gland 

* “The Abderhalden Reaction in Mental Disease,’’ Cotton, Corson 
White and Stedman, Journal of Nervous and Mental Diseases, 1917. 

419 


420 MIND AND ITS DISORDERS 


occurring in association with the menopause or as a sequel to 
some acute specific fever, acute rheumatism, syphilis or facial 
erysipelas. In other cases the thyroid is enlarged by the in- 
filtration of a new growth, the glandular tissue proper being 
destroyed. Myxcedema sometimes appears as a sequel to ex- 
ophthalmic goitre, the former enlargement of the thyroid being 
replaced by atrophy. The disease begins most commonly be- 
tween the ages of thirty-five and fifty-five and occurs much more ~ 
frequently in women than in men. 

The active principle of the internal secretion of the thyroid 
contains iodine and has been named “ thyro-iodine’’. It is 
obtainable by boiling fresh glands in sulphuric acid (ro per cent.), 
filtering off the precipitate and removing fats by trituration 
with petroleum-ether and alcohol. The thyro-iodine is then 
dissolved in a solution of sodium hydrate (1 per cent.) and 
reprecipitated by the addition of dilute sulphuric acid. The 
precipitate, a brown amorphous powder, is purified by repeated 
washings in distilled water and then dried. In obtaining it 
for medicinal purposes it is found that the thyroid of the sheep 
gives the largest yield. 

The function of this substance in the organism is either to 
destroy mucinoid products formed in the tissues or to prevent 
their formation. Horsley concluded from his experiments that 
it transformed mucinoid products into substances which were of 
some service to the organism. Since then it has been demon- 
strated that there is an intimate relationship between the thyroid 
and the other endocrine organs, especially with the sex glands. _ 

Physical Signs.—The appearance of the patient is very charac- 
teristic. The subcutaneous tissues all over the body are swollen, 
the aspect being that of general cedema; but the tissues do not 
pit on pressure nor is there any exudation of serum on punc- 
turing the skin. The face is swollen, especially the eyelids, so 
that the palpebral fissure is narrowed, and there is in some 
cases over-action of the frontales similar to that seen in associa- 
tion with paralytic ptosis. This swelling of the face not only 
hampers the movements of the facial muscles, it also obliterates 
all the lines of expression. With the exception of a characteristic 
flush over the malar eminences the complexion is sallow. | 

The secretion of sweat being diminished, the skin is dry and 
rough; the hair is dry, loses its lustre and is apt to fall out, and 
the nails are longitudinally striated and liable to split. 

Owing to swelling of the tongue the patient has difficulty 
of articulation and of deglutition and, owing to swelling of the 


MYXC@DEMA 421 


vocal cords, the voice is low-pitched and raucous. Myxcedema- 
tous patients are always constipated. 

The pulse is infrequent, feeble, irregular and of low tension. 
Examination of the blood reveals a slight diminution of the red 
corpuscles and also of the white. Epistaxis is common and 
difficult to arrest, menstruation is excessive and, in the case of 
childbirth, post-partum hemorrhage is to be feared. Similarly 
the hemorrhage from small wounds such as that left by the 
extraction of a tooth is often troublesome. The temperature is 
subnormal. The excretion of urea is always diminished, and 
albuminuria occurs in many cases. 

The patients are torpid and disinclined to occupy themselves 
or to move about from place to place. The tendon reflexes are 
diminished, but there are no other physical signs of disease of 
the nervous system. 

Mental Symptoms.—Patients suffering from myxcedema usually 
feel cold; they complain especially of a subjective feeling of cold- 
ness internally. Buzzing in the ears is also a common 
complaint. 

On examination we find that there is no loss of any form of 
sensation. It has been stated by some observers that there is 
delay in the transmission of tactile sensations, but it is probably 
more correct to say that there is delay in the motor response 
to a tactile stimulus. 

The faculty of perception is somewhat deficient owing to 
defect of attention, and the patients have difficulty in grasping 
the meaning of simple sentences, written or spoken. Memory- 
images (ideation) are not easily called up and the association 
of ideas (train of thought) is impeded. The memory for remote 
events is good, but that for recent events is impaired because 
the attention to passing events is insufficient to allow them to 
make a lasting impression (anterograde amnesia). 

Emotional reaction being deficient, the patients are apathetic 
and torpid. Activity of all kinds is diminished and slow. There 
is little or no instinctive desire to be up and doing. As a rule 
they are disinclined to talk, but this is not invariably the case. 
Volitional and automatic actions are as few as possible. The 
patients will get up and dress in the morning, but they take 
hours to do so. They eat their meals, keep themselves fairly 
clean and tidy and perform all the necessary daily functions; 
but slowness in performance is characteristic of them all. 

The above is the clinical picture of an extreme case, but the 
medical man should be on the alert for mild cases exhibiting 


422 MIND AND ITS DISORDERS 


merely, for example, depression, infrequent pulse, mental de- 
pression and a malar flush. 

Morbid Anatomy and Psychopathology.—The condition of the 
thyroid has already been mentioned. The connective tissue 
throughout the body is infiltrated with a jelly-like substance to 
such an extent as to cause compression of the parenchyma of the 
various organs and to interfere with their function. No changes 
have, however, been discovered in the central nervous system. 

From a psychological standpoint myxcedema is a very interest- 
ing disease in that the psychical disabilities of the patient can 
all be explained by the mechanical interference of the motor 
functions. The muscle fibres being compressed by the mucinoid 
substance, volitional and instinctive movements are all rendered 
difficult of performance. By the same mechanism the muscular, 
glandular and even vasomotor changes constituting emotional 
reaction are impeded so that the patient does not experience 
emotion. Similarly there is an impediment to that muscular 
adjustment of the organism to facilitate the reception of sensory 
impressions, which we call attention; and the difficulty of per- 
ception, retardation of the association of ideas and inability 
to retain new impressions may all be traced to this defect of 
attention. 

Although no histological changes in the nervous system have 
as yet been described in association with myxcedema and 
although the mental symptoms are all referable to mechanical 
interference with the musculature, it is not to be supposed that 
the central nervous system is unaffected by the toxin which 
presumably circulates in the blood owing to the absence of the 
neutralizing influence of the internal secretion of the thyroid. 
On the contrary the mere fact that the natural termination of 
the disease is coma is antagonistic to such a view. 

Course and Prognosis.—In the absence of treatment myx- 
cedema is a progressive disorder, terminating fatally. The power 
of resistance of the tissues to infection is lowered, so that many 
of the patients die of some intercurrent disease, especially 
tuberculosis. If, however, the disease runs its course and death 
is directly due to myxcedema, extreme physical weakness sets 
in towards the end, the body shrinks and wastes and the patient 
dies comatose. It is remarkable in such cases that the mucinoid 
substance is not to be discovered in the tissues after death. 

Treatment.—This consists in the administration of thyro- 
iodine. It is usually given in the form of the dried thyroid 
gland of the sheep. It is necessary to start with small doses 


CRETINISM 423 


(the equivalent of $ to I grain of the fresh gland daily) and to 
work up gradually to larger quantities. The patient should 
keep his bed during the first few weeks of treatment. Indica- 
tions that he is receiving too large a dose of thyro-iodine are 
tremor of the fingers, rise of temperature and acceleration of 
the pulse-rate. 

Even when all the symptoms of myxcedema have disappeared 
the patient must continue to take the drug regularly for the 
rest of his life in order to prevent recurrence of the disease, the 
dose being kept as small as is compatible with his health. 


CRETINISM. 


This is a state of defective mental and physical development 
due to congenital deficiency or absence of the thyroid body. 

Etiology.—The disease is endemic in certain mountainous 
districts on the Continent; in this country it occurs only sporadi- 
cally. Where it is endemic the drinking-water is usually held 
responsible, probably with reason, for the disease has been 
stamped out in one or two villages by inducing the inhabitants 
to substitute rain-water for drinking purposes. Analysis of the 
spring-water of cretinogenous districts has shown that it usually 
contains chalk, sulphide of iron and sulphate of magnesium. 
There is some evidence that endemic goitre is caused by a micro- 
organism, since it can be prevented by passing the water of the 
locality through a Berkefeld filter before allowing it to be used 
for drinking purposes; but it has not yet been ascertained whether 
endemic cretinism can be prevented in the same way. The cause 
of sporadic cretinism remains to be discovered. The disease is 
slightly more frequent in girls than in boys. 

Physical Signs.—The first signs of cretinism are seldom observed 
before the sixth month, sometimes not until the child has attained 
the age of two years, or even later. It is then noticed that 
growth is retarded or irregular, the body not keeping pace with 
the head, that the voice is hoarse, low-pitched and unnatural, 
the skin harsh and dry and the abdomen unduly prominent. 
Examination of the thyroid region reveals either absence of the 
gland or the presence of a small goitre. 

If the disease be left untreated, the body remains stunted in 
growth and the infantile condition persists, so that a cretin of 
twenty years of age may look like a child of four. The cretin 
differs, however, from a normal infant in presenting many 
deformities. 


424 MIND AND ITS DISORDERS 


The head is too large for the body and the spinal muscles are 
too weak to hold it up, so that the chin is liable to sink on the 
chest. As a result the shoulders become rounded and there is 
compensatory lordosis in the lumbar region, the aspect of which 
is enhanced by the swollen belly. The limbs are short and the 
tibiz may curve outwards as in rickets. The hands and fingers 


Fics. 66 AND 67.—M. B., &T. 16 YEARS. SPORADIC CASE OF CRETINISM 
FROM BERKSHIRE. 


are stubby and the ligaments lax, so that the fingers can be 
bent backwards to a right angle. 

The head is elongated and, especially in the occipital region, 
broad. On the top it is flat. There is undue separation between 
the eyes. 

The integuments are swollen and look cedematous > Duteas 
in myxcedema, they do not pit on pressure nor is there any 
exudation of serum when the skin is punctured. The face 


CRETINISM A25 


and nose are broad and puffy, the lips thick and the eyelids 
swollen. These features taken in conjunction with the swollen 
abdomen and the podgy limbs give the child a very characteristic 
appearance. 

The swelling also affects the mucous membranes. The tongue 
is swollen, often projecting between the incisor teeth; and there 
is swelling of the soft palate and laryngeal tissues as in myX- 
cedema. 

Soft lobulated lipomata, each about the size of a hen’s egg, 
are to be felt in the supra-clavicular regions and less frequently 
in the axillz. 

The temperature is subnormal and the pulse-rate slightly 
increased. Examination of the blood reveals a diminished 
number of the red corpuscles and diminution of hamoglobin. 
The leucocytes are also fewer than normal. 

Dentition is late and the teeth are very liable to become 
carious. The sexual apparatus and the genital functions develop 
late or not at all. 

Mental Symptoms.—Intellectual deficiency which in many 
cases amounts to an extreme form of idiocy is characteristic of 
this condition. 

Three grades are recognized: 

1. Cretins in whom mental activity is at the very lowest 
ebb, who are in a perpetual state of somnolence, who utter no 
articulate sounds and whose sole evidence of mentation is the 
emission of strident cries of satisfaction or dissent when food 1s 
given or not given to them; 

2. Semi-cretins who are able to walk a few paces slowly and 
with difficulty, to speak a few words and to learn how to perform 
a few simple acts; and 

3. Cretinoids whose mental development is less retarded than 
that of the semi-cretins; these are to be regarded as imbeciles 
rather than idiots. 

The mental condition associated with cretinism differs little 
from other forms of idiocy and imbecility. The cretin is perhaps 
of a gentler disposition; he possesses fewer criminal instincts 
and his movements are slower than those of other feeble-minded 
children. 

Morbid Anatomy and Pathology.—As in myxcedema, all the 
tissues are infiltrated with mucinoid products and the thyroid 
is absent, diminutive or goitrous. The shape of the skull was 
ascribed by Virchow to premature synostosis between the basilar 
portions of the sphenoid and occipital bones. The sella turcica 


426 MIND AND ITS DISORDERS 


is small, the clivus steep and the foramen magnum smaller than 
natural. 

Macroscopically the nervous system appears to be fairly 
normal. Under the microscope the cortical nerve-cells are seen 
to be slightly smaller than the normal and they tend to be globose 
as in other forms of idiocy. 

Prognosis.—In cases of pure cretinism, not cretinism plus 
genetous idiocy, the prognosis is favourable if treatment is begun 
early, before the child is three years of age. Physical improve- 
ment can be accomplished at any time of life by the administra- 
tion of thyroid, but the longer treatment is delayed the smaller 
is the amount of intellectual improvement to be expected. 

Treatment.—The patient should be removed to a healthy 
neighbourhood or at least to a district where the drinking- 
water is pure and iron-free. Dried thyroid should be adminis- 
tered as in myxcedema. The equivalent of not more than 
10 grains of the fresh gland per week may be given at first and 
this dose may be gradually increased until at the end of six 
months the patient is taking the equivalent of Io or I5 grains 
daily. This latter dose must be continued during the remainder 
of the patient’s life if relapse is to be avoided. Under this 
régime the patient grows rapidly (about 4 inches a year at 
first), the swelling of the integuments and the supraclavicular 
lipomata disappear, the skin tightens and gets soft and supple, 
the temperature rises to normal, the blood becomes normal 
and the child active and intelligent. During the rapid growth 
the legs are liable to become bowed, owing to the cartilage 
of the long bones growing faster than the ossifying portions. 
To prevent this deformity it may be desirable that some form 
of apparatus be worn for the purpose of giving lateral support 
to the legs until the greater part of the epiphyseal cartilages has 
become ossified. 


THE PiTuITARY Bopy. 


An extensive study of this organ during recent years, especially 
by Cushing, has revealed that it consists of two entirely dis- 
similar parts possessing separate functions, the anterior half 
affecting the growth of the organism and the posterior controlling 
its carbohydrate metabolism. Either or both of these may be 
hypertrophied or more or less destroyed by disease (atrophy, 
sclerosis or tumour) and consequently there is a considerable 
variety of clinical pictures arising from pituitary affections, 


THE PITUITARY 427 


according to the degree or manner in which the anterior and 
posterior lobes are involved. 

Disease or atrophy of the anterior portion results in asthenia, 
chilliness, excessive thirst with polyuria, adiposis of the femi- 
nine type perhaps with pendulous breasts, enlargement of the 
pelvis which is similar in type to that of the female, atrophy of 
the testes, epididymes and spermatic cords, absence of pubic and 
axillary hair (infantilism) and a pale, waxy, wrinkled face. 

Mentally these patients are dull, apathetic or depressed, and 
intellectually stupid. In some patients there is definite con- 
fusion with imperception, disorientation and failure of memory. 
They are lacking in energy and initiative in conduct and con- 
versation and their speech is somewhat drawling. Drs. Prior 
and Evan Jones of New South Wales have found cases of this 
type among their epileptic patients. 

Hypertrophy of the anterior portion during early life causes 
gigantism or precocious development, especially in respect of 
the growth of hair about the face, pubes and axille and of 
the genitalia. In later life this hypertrophy gives rise to 
acromegaly. 

Mentally, so far as I am aware, these patients are unaffected. 

Disease or atrophy of the posterior portion is mainly character- 
ized by an abnormal tolerance of sugar. Some of these patients 
can take as much as 300 grammes daily without rendering the 
urine capable of reducing Fehling’s solution. 

The mental symptoms in such cases are usually of the con- 
fusional type: imperception, hallucinations (especially of vision), 
disorientation, failure of memory, lack of voluntary attention 
and a general clouding of consciousness. 

Hypertrophy of the posterior portion gives rise to an alimentary 
glycosuria, by which is meant that the glycosuria occurs after the 
ingestion of food. The affection does not appear to be associated 
with mental disorder. 

In short, it would seem that mental disorder arises only from 
destruction or atrophy of the pituitary body, not from its hyper- 
trophy. When confusional symptoms arise they probably in- 
dicate some affection of the posterior lobe; but it is likely that 
both anterior and posterior hypopituitary mental symptoms 
are of toxic origin. The depression associated with anterior 
hypopituitarism cannot be ascribed to changes in the blood- 
pressure because the substance which raises the blood-pressure 
is derived from the posterior part only (from the pars intermedia 
originally). 


428 MIND AND ITS DISORDERS 


Treatment.—Specific treatment consists of giving pituitary 
extract of which the organism stands in need (the anterior and 
posterior extracts can be obtained separately, as required); but 
it is found in many cases that thyro-iodine, thyro-glandin or 
some such preparation has a more gratifying result clinically 
than pituitary preparations. In this connection the intimate 
physiological relationship between the thyroid and pituitary will 
naturally occur to the reader. 

Apart from specific treatment the various mental symptoms 
can be dealt with as they arise, on general medical principles. 


THE SUPRARENALS. 


Most patients suffering from Addison’s disease are free from 
mental symptoms except during a terminal delirium, sometimes 
accompanied by convulsions. 

In rare cases, usually running a chronic course, the patients 
are liable to attacks of depression with lack of initiative, dis- 
tractibility and excessive emotionalism (flow of tears etc.). 

Gallais* has reported the case of a patient suffering from 
Addison’s disease of twenty years’ standing, who suffered from 
mental attacks of this kind accompanied by auditory hallu- 
cinations and delusions of persecution, this state alternating 
with attacks of furious maniacal excitement, logorrhcea, euphoria 
and motor agitation. The change from depression to excite- 
ment was invariably accompanied by a rise of blood-pressure. 
The observation may be important because Craig, in his study 
of the blood-pressure in maniacal-depressive insanity, found it 
to be high in melancholia and low in mania. 

In view of the observation mentioned on page 368, it seems 
probable that the suprarenals may have an important relation- 
ship with epilepsy. 

Treatment.—The symptoms are invariably relieved by the 
administration of adrenalin. 


THE PINEAL. 


Tumours destroying this body, which are of rare occurrence, 
usually occur in childhood and then give rise to premature 
development of the sexual organs and characters, at any rate 
in the male. In association with this physical peculiarity the 
patients are sometimes, perhaps usually, precocious in their 
mental evolution. On the other hand, the tumour may either 


* Rev. Neurologique, 19tt. 


ENDOCRINAL INSANITIES 429 


retard mental development by obstructing the flow of cerebro- 
spinal fluid through the iter, thus causing hydrocephalus (q.v.), 
or induce mental hebetude in the same way as any other intra- 
cranial tumour. 


THE SEX GLANDS. 


The physical and mental results of castration and oophcrec- 
tomy, generally infantilism with an approximation of the 
patient’s characteristics to those of the opposite sex, are con- 
sidered to be so well known that they are taken for granted; 
so much so that I am not aware of a single paper systematically 
recording the results of scientific observation in these cases. 

After recent oophorectomy there is sometimes a short attack 
of depression scarcely distinguishable from true melancholia 
and most physicians for mental disease have had psychotic 
patients whose ovaries had been removed some years previously ; 
but, so far as I am aware, there has been no collective investi- 
gation of these cases to determine whether the mental disorder 
is directly due to lack of the ovarian endocrine. 

Pages 319 and 340 should here be read again in view of a 
possible relationship between dementia preecox and atrophy of 
the sex glands. 


THE PARATHYROIDS, THYMUS, PANCREAS ETC. 


So far as our knowledge goes there is no specific mental 
disorder associated with disease of these bodies; but clinical 
study of this group of organs is yet in its infancy respecting 
their mental as well as their physical activities. 


ORGANIC INSANITIES. 


THESE result directly from organic disease of the brain, which 
may be either partial destruction of the organ (for example, 
from thrombosis of the middle cerebral artery of one side), in- 
flammation of the cerebrum or the meninges or widespread 
degenerate changes. 

It is remarkable that the commonest destructive lesions, such 
as the above-mentioned which causes ordinary hemiplegia, give 
rise to comparatively little mental disturbance. The obliteration 
of projection areas has but little effect on mentation; but destruc- 
tion of those parts of the cerebrum which contain fibres essential 
to the association of ideas (association-fibres) naturally causes 
some degree of dementia, which may be considerable, varying 
with the site and size of the lesion. 

On the other hand, widespread microscopic degenerative 
changes may induce the most profound and complicated mental 
disorder because, during even the earlier stages of such maladies, 
there is extensive interference of function but little destruction. 
The psychical result of such interference is the escape of normal 
complexes from vepression so that they find éxpression, usually 
in the distorted form of bizarre symptoms. This is a point 
which requires emphasizing, viz., that the psychical mechanism 
underlying these insanities is the same as that underlying other 
mental disorders, the only difference being that the bonds of 
repression are burst because they are weakened by organic 
disease and not merely on account of the irresistible force of 
the escaping complex. 

These remarks especially apply to the first disorder described 
under this group; but—by way of elucidation—let us momen- 
tarily revert to the subject of alcoholism. In the earlier stages 
a man seeks relief from his unrecognized conflict by indulgence 
in alcohol for various unconscious reasons; but alcohol in large 
quantities induces physical degeneration of the cortical neurons 
and therefore of the mental repressing forces. The repressing 
forces being weakened, this time through physical degeneration 
of the nervous system, the patient is obliged to take more and 

aS, 


GENERAL PARALYSIS A3I 


more doses of alcohol to relieve the mental conflict, not only 
because the unrecognized complex is forcibly striving for ex- 
pression, but also because the repressing forces are organically 
weakened. 


CHAPTER-XVII- 
GENERAL PARALYSIS (DEMENTIA PARALYTICA). 


GENERAL PARALYSIS is an organic disease of the cerebral cortex 
usually occurring in the fourth decade of life, possessing a large 
array of clinical symptoms, leading to progressive motor para- 
lysis and profound mental deterioration, and terminating fatally, 
with very few exceptions, in two or three years. For some 
reason or other it is less prevalent than it used to be. According 
to the statistics of the Board of Control, it was responsible from 
1878 to 1914 for 7-6 per cent. of the admissions to asylums, the 
lowest being 6-I per cent. in 1902; but during the years 1920- 
1922 it accounted for only 5-7 per cent. The reason for this is 
unknown, and it has been stated definitely that the salvarsan 
treatment of syphilis is not responsible for the change. 

Etiology.—In previous editions an overwhelming mass of 
evidence was given in support of the hypothesis that general 
paralysis was a sequel to syphilis. This is no longer necessary 
since Noguchi demonstrated the presence of spirochetes in 
the cerebral cortex of patients who had died from the disease. 
This observation has been confirmed by many neuropathologists 
and, I believe, refuted by none. Moreover, it is now generally 
accepted that the Wassermann reaction is nearly always positive 
in the cerebro-spinal fluid and also, though not quite so fre- 
quently, in the blood. The reaction tends to disappear as the 
disease progresses. When a negative result is obtained in an 
early case, the positive reaction is almost sure to occur at some 
subsequent examination, perhaps a few weeks later. 

General paralysis usually develops about ten years after 
syphilitic infection; it is usually, therefore, a disease of the 
fourth decade. I have, however, seen cases occurring as early 
as two years and as late as thirty-two years after infection, the 
disease appearing in this last patient at sixty-three years of age. 

““ Juvenile ’’ cases occur as a sequel to congenital syphilis, the 
_ earliest case I have seen being in a child of seven. On the other 
hand, general paralysis due to congenital syphilis may develop 
as late as twenty-eight years of age. 


432 MIND AND ITS DISORDERS 


Adult general paralysis occurs in the pauper class four times 
as frequently in men as in women, and in the private class fifteen 
times as frequently. This difference between the two classes is 
what we should expect on the supposition that syphilis is the 
cause of general paralysis, in view of their different social customs. 
We may correlate the pauper statistics with the statement from 
Denmark, where syphilis is a notifiable disease, that syphilis 
occurs four times as frequently in men as in women. 

Adolescent and juvenile general paralysis occur with almost 
equal frequency in males and females, females preponderating 
to a slight extent. This also is what would be expected of a 
malady due to congenital syphilis. Males and females are 
equally exposed to the inheritance of syphilis; general paralysis 
would therefore be expected to be equally distributed between 
the sexes in the juvenile and adolescent cases, with a slight 
preponderance of females as in the general population. 

The professions are represented among general paralytics in 
proportions which are in accordance with the syphilitic origin 
of the disease. For example, one-third of Hirschl’s cases and 
two-thirds of Garbini’s cases belonged to the labouring class, 
go per cent. of Krafft-Ebing’s cases were officers in the army, 
while Hirsch] had only one Roman Catholic priest among his 
200 general paralytics and Krafft-Ebing had no such instance 
among his 2,000 cases. Salaris stated that there was only one 
case occurring in Sardinia during the years 1891-1897 in a priest, 
and that priest had certainly had syphilis. Bouchard also 
demonstrated the infrequency of general paralysis among the 
clergy. 

The geographical and racial distribution of general paralysis - 
are of considerable interest.. In Macpherson’s “‘ Mental Affec- 
tions ’’ the author remarks: “It may be generally stated that 
the disease does not exist in the Highlands of Scotland or in 
Ireland outside the larger cities, or in the more rural and remote 
districts of Wales and the South of England. It reaches its 
maximum in the busy manufacturing towns of the Midlands, 
and in the larger cities of the United Kingdom.” Similar 
remarks apply to Sweden. The author continues: “‘ Taking a 
wider geographical area, it is present in the countries of Western 
Europe and North America, and is practically unknown among 
the uncivilized nations of the world !”’ 

In Germany general paralysis has invaded the more rural 
districts to a greater extent than formerly; but this can be 
accounted for by the military organization which exists there, 


GENERAL PARALYSIS AND SYPHILIS 433 


whereby every man is exposed in his youth to barrack-room life 
and syphilization. 

This distribution of general paralysis corresponds fairly well 
with the distribution of syphilis; the latter disease, however, is 
rather more widely spread and there are some special countries 
which demand closer investigation. 

Until the last decade both syphilis and general paralysis were 
rare diseases in Iceland, but now syphilis may be regarded as 
endemic there and by no means uncommon. General paralysis 
is, however, still rare and, curiously enough, the pathologists at 
Reykjavik (the capital of the island) are remarkably insistent 
that repeated investigations of these cases yield decidedly 
negative results respecting their syphilitic origin. Similarly, 
syphilis is rife in China, Japan, and the Mohammedan 
countries, while general paralysis is said to be comparatively 
rare. 

Basing. conclusions upon the racial distribution it has often 
been argued that general paralysis is essentially a disease of 
civilization. 

It is noteworthy that only about 3 per cent. of syphilitics 
develop general paralysis, and I think that this fact has been 
adequately explained by Mott. In a paper in the British 
Medical Journal of January 4, 1908, he brought forward striking 
evidence’ that there may be a special neurotoxic variety of the 
Spirochata pallida or Treponema pallidum—in other words, 
there is probably a special general-paralysis-producing variety 
of syphilis. 

In view of the fact that ordinary syphilitic manifestations 
(irites, gummata etc.) are extraordinarily rare in patients suffer- 
ing from general paralysis I suggest, in amplification of Mott’s 
observations, that the spirochete of general paralysis (and tabes 
dorsalis) is specific and that, in spite of its biological resemblances 
to that of syphilis, the two are not identical. According to this 
view general paralysis is a specific (venereal) disease and general 
paralytics who exhibit the ordinary manifestations of true 
syphilis must be regarded as patients who have contracted two 
separate specific diseases, possibly at the same time, viz., general 
paralysis and syphilis. 

It is remarkable, in view of our conclusions, that there is no 
record of any asylum pathologist or attendant on the insane 
having contracted general paralysis from one. of his patients. 
The observation is gratifying, but the fact is rather difficult to 
explain. 

28 


434 MIND AND ITS DISORDERS 


Physical Signs.—Although tertiary manifestations of syphilis 
are of rare occurrence in general paralysis, tabes dorsalis, which 
has also been regarded as a late sequel to syphilis, is recognizable 
clinically in about 25 per cent. of the cases, and some degeneration 
of the posterior columns can be discovered post mortem in nearly 
every case. 

It is found clinically that tabes associated with general 
paralysis is seldom very advanced and the diagnosis, as a rule, 
depends merely on the association of absence of knee-jerks 
with loss of the pupillary light reflexes. Anesthesia, lightning 
pains and extreme inco-ordination are exceptional. 

Epileptic and epileptiform (Jacksonian) convulsions and so- 
called apoplectiform attacks are manifestations liable to occur at 
any time in the course of the disease; they may be the initial 
symptom calling attention to the patient’s condition or they 
may be the concluding event determining the fatal issue. They 
are, however, most common in the second stage. 

Epileptic fits occurring in the course of general paralysis are in 
no way distinguishable from those seen in idiopathic epilepsy. 
Batches of fits are not infrequent, giving rise to a true status 
epilepticus. Isolated fits occur in all degrees of severity and I 
have seen attacks indistinguishable from minor epilepsy followed 
by typical post-epileptic automatism. 

Similarly local fits without loss of consciousness, in no way 
distinguishable from the Jacksonian convulsions seen in cases of 
subcortical tumour, are liable to occur in general paralysis. 
Naturally enough, they begin most frequently in the thumb 
and forefinger of the right hand, opposition of the thumb being 
the most recently evolved, most voluntary, and therefore most 
unstable motor function of the cortex. The convulsion travels 
up the arm, usually as far as the shoulder, and leaves the limb 
paralyzed for some hours or days after the attack. 

In an apoplectiform attack similar local paralysis occurs without 
previous convulsion and, in like manner, passes off within a few 
days. Such an attack is usually associated with disturbance 
of consciousness, varying in degree from mere somnolence and 
confusion to a condition resembling true apoplexy with coma 
and stertorous breathing. As consciousness is restored, it is 
found that the patient is suffering from hemiplegia or brachial 
monoplegia (both are usually on the right side), accompanied 
perhaps by motor aphasia and apraxia. Sensory and motor 
aphasia may also occur independently of other paralyses. All. 
these paralyses pass away in the course of a few days or weeks. 


PHYSICAL SIGNS OF GENERAL PARALYSIS 435 


Closely allied to these are attacks of fever in which the patient’s 
temperature rises above 100° F., perhaps to 104° F., no visceral 
or other lesion being discoverable to account for the rise. It 
has therefore been ascribed to disturbance of the heat-regulating 
centres, especially of the vasomotor centre, since the attacks are 
frequently accompanied by pallor or, more often, by flushing 
and swelling of the face. 

The so-called automatic movements of general paralysis may 
be most appropriately mentioned in this place, since they are to 
be regarded as more or less of the nature of a chronic convul- 
sion. They are imstinctive rather than automatic and consist 
of constant involuntary movements, usually about the mouth, 
movements of sucking, chewing, smacking the lips, tasting, 
deglutition and grinding of the teeth. Picking of the nails also 
occurs with some frequency. 

Perhaps the commonest and most characteristic motor dis- 
turbance is tremor, especially about the face, tongue and hands. 
The lower part of the face is most affected, in contradistinction 
to alcoholic tremor which affects mostly the upper part of the 
face. If the patient be asked to show his teeth, the upper lip 
is seen to be tremulous owing to weakness of the levators and 
zygomatics. 

The lingual tremor is best seen when the patient is directed to 
protrude his tongue slowly. Characteristically it is an antero- 
posterior tremor, so-called trombone movement, not a rippling 
on the surface of the tongue as in alcoholism. I have several 
times observed tremor of the uvula in general paralysis. 

Hand tremor is best elicited by getting the patient to extend and 
separate the fingers, the wrist being extended at the same time. 

Weakness of the lower limbs sets in as the disease advances. 
The gait becomes at first shuffling like that of an old man, the 
patient scarcely raising his feet from the ground, so that he is 
liable to stumble over slight obstacles. Later the gait becomes 
tottering and finally the patient has to be kept in bed to avoid 
falls. Here contracture of the flexor muscles sets in and pro- 
gresses until the patient’s knees are almost up to his chin. 

The muscles waste, especially the interossei and the muscles 
of the thenar and hypothenar eminences, and Lenzi has found 
on electrical examination in some cases kathodal closure con- 
traction equal to anodal closure contraction. 

The commonest pupillary change in general paralysis is slug- 
gishness, diminution or absence of the reflex to light on both 
sides. This is one of the cardinal signs of the disease; but I have 


436 MIND AND ITS DISORDERS 


met with several cases in which the disease ran its course without 
loss of reaction to light at any stage. Marandon de Montyel, 
however, who made a careful examination of the pupil reflex in 
140 general paralytics from the onset of the disease to the death 
of the patient, states that in no case did he find the pupils normal 
from beginning to end. He found in some cases exaggeration of 
the reflex in the initial phase, and that this was always succeeded ~ 
by diminution; but I have been unable to confirm this observa- 
tion. Consensual pupillary reaction, contraction when light is 
thrown into the opposite eye, may be abolished before, simul- 
taneously with or subsequently to loss of the direct reflex. 
Dr. Bevan Lewis considered loss of the sympathetic reflex to 
be the earliest pupillary sign of general paralysis (dilatation on 
pinching the skin of the neck). 

In some cases loss of the light reflex is coupled with loss or 
diminution of the pupillary contraction associated with con- 
vergence (often called erroneously the “‘ reaction to accom- 
modation ’’). This sign is occasionally unilateral, with the result 
that the pupils are markedly unequal in diameter, the difference 
being often as much as, or even more than, 2 millimetres. 

Occasionally the pupils are eccentric, of irregular outline 
or oval. Pilcz, Marina and others have shown that these 
phenomena are due to disease of the ciliary ganglia. 

Nystagmus and, in the tabetic cases, ptosis are sometimes 
observed. 

There is almost always some contraction of the visual field 
in general paralysis. Optic atrophy, although fairly frequent, 
is usually slight; but it may be complete in some tabetic cases. 
I have seen one (atypical) case of complete optic atrophy in 
general paralysis with exaggerated knee-jerks. In 1881 he had 
forty-three boils on his body (? syphilis) ; in 1882 loss of memory 
and difficulty of articulation which cleared up in six weeks; 
in 1888 he gradually lost the sight of his right eye, and in 1894 
he was admitted to Bethlem with general paralysis, complete 
optic atrophy in the right eye and partial atrophy, which in- 
creased under observation, in the left. He died of the disease 
in 18096. 

Kéravel and Raviart state that sclerosis of the optic nerve 
in tabes is insular, but in general paralysis annular. In the 
author’s experience there is this clinical difference—that in tabes 
the physiological cup tends to be filled in more than in general 
paralysis. A slight amount of swelling of the disc (4 to 1 diopter) 
may occur in the early stages of the disease. 


CEREBRO-SPINAL FLUID 437 


In depressed cases the superficial reflexes are commonly 
diminished or absent, especially the scapular, epigastric, ab- 
dominal, cremasteric and gluteal. Stroking the sole of the foot 
almost invariably elicits a flexor response (except after a seizure) ; 
but I have seen an extensor response in four cases. The pharyn- 
geal reflex is almost always abolished, frequently in the earlier 
stages of the disease, invariably in the latter. 

The tendon reflexes are abolished in the tabetic patients 
(about 25 per cent.), exaggerated in the remainder. This 
exaggeration is well marked in both upper and lower limbs. 
Ankle-clonus does not occur in uncomplicated cases. The 
exaggeration of the knee-jerk is almost characteristic in that the 
excursion of the foot is large, the anterior movement lively, but 
the return (semimembranosus action) sluggish. As a result, the 
knee-jerk has a “ floppy ’’ aspect. This exaggeration of the knee- 
jerk becomes less marked as the disease advances. 

Malnutrition of the skin is evidenced by the furrowed nails 
and “‘ glossy skin ’’ frequently seen in the hand and feet. Bed- 
sores are liable to occur at points of pressure, especially over 
the sacrum, buttocks and trochanters; mainly because the 
patients lose control, first of the bladder, then of the rectum, 
in the terminal stages of the disease. 

Frequently retention of urine is an early symptom demanding 
the passage of a catheter. There is an increase in the quantity 
of urine passed during the twenty-four hours. In other cases 
the urine dribbles away from a full bladder, apparently owing 
to relaxation of the sphincter vesice. 

Signs of arterial degeneration may be observed in some cases, 
a distinct jog being noticeable in listening over the first part of 
the aorta with a wooden stethoscope (dilated aorta). The blood- 
pressure is usually raised. 

The cerebro-spinal fluid is characterized by: 

(a) Leucocytosis, the presence of plasma cells being pathogno- 
monic of general paralysis (Fig. 69) ; 

(b) Excess of globulin, instead of the normal infinitesimally 
small amount; 

(c) A positive Wassermann reaction in the majority of cases 
or, as some observers state, in all cases of general paralysis; 

(2) Increased pressure, which causes it to spurt out almost like 
a stream of urine when a lumbar puncture is made.* ) 

Mental Symptoms.—General paralysis is a disease tending to 
the progressive destruction of the whole nervous system. Accord- 

* For further details see Appendix B. 


438 MIND AND ITS DISORDERS © 


ingly we find that the earliest symptoms of the disease consist 
of deterioration of those functions of the nervous system which 
were the latest to be acquired. The patient’s accomplishments 
are not up to their former standard of excellence, the business 
man fails to drive a bargain with his former success, the artist’s 
pictures lack their earlier vigour and the musician’s performances 
receive no encore as of old. It is usually said that the memory 
for recent events and proper names is faulty, but the ordinary ~ 
systematic examination usually fails to confirm this statement. 
The failure of memory is of another order; the patient forgets 
resolutions. He forgets to post letters, to catch a train, to 
keep an appointment or to take his keys with him, perhaps 
leaving them dangling from the lock of his safe. Dr. Mercier 
has humorously called this symptom “ loss of memory for future 
events’. In the later stages of the disease the general paralytic 
becomes incapable of recognizing friends and relations. 

Apart from the tabetic cases, there is frequently in the early 
stages some loss of cutaneous sensation ; but in the most advanced 
stages the patient responds to a pin-prick in any part of the body. 
It must be admitted, however, that there is no means of ascertain- 
ing whether the response is purely reflex or dependent on cortical 
activity. Hyperzsthesia occurs in some of the excited cases. 

Attention has been directed to anesthesia of the ulnar nerve 
in general paralysis, the “‘ funny-bone ”’ sensation being absent 
when the nerve is nipped on the inner side of the elbow. In 
the author’s experience, this symptom occurs in less than half 
the cases; moreover, it is present in a considerable number of 
normal people. 

The olfactory sense is frequently lost on one or both sides 
(anosmia) and there is often diminution of the sense of taste 
(ageusia), especially for salt. The sense of hearing is almost 
invariably diminished in the late stages, sometimes in the earlier 
stages of the disease; but there appears to be no limitation of 
the range of hearing, the high notes of a Galton’s whistle being 
heard as well as formerly, if they are loud enough. 

Hallucinations of vision or of hearing occur in about 25 per 
cent. of the cases, but they seldom form a prominent feature in 
the clinical picture. Perception remains fairly good as a rule 
until the later stages of the disease, when the patient gradually 
becomes more and more oblivious of his surroundings and 
incapable of apprehending their nature (imperception). The 
appreciation of time and space necessarily disappears pari passu 
with ideation and perception. 


GENERAL PARALYTIC DELUSIONS 439 


Judgment and reasoning are impaired almost from the first 
and delusion is the rule. In the classical form of the disease 
the delusions are expansive in nature. The patient believes 
himself to be possessed of wealth beyond the dreams of avarice; 
his treasures are to be measured, not by millions, but by ship- 
loads and his estates comprise gold-mines and continents. He 
is a mile high and weighs tons. He is King, Emperor, nay, 
God Himself. He can slay his millions or raise the dead at 
will. He can play a hundred instruments and speak a thousand 
tongues; but, on being asked to give an example of any one of 
these, he will break into an unintelligible jargon. He will tell 
you that he is the champion runner for all distances and, being 
asked his time for the hundred yards, display utter ignorance 
of athletics by answering “‘ Three minutes ’’. 

Although the classical type of delusion in general paralysis 
is of the expansive variety, fancies of this nature appear to be 
nowadays less common than in former years. Melancholiac and 
hypochondriacal delusions are now more frequently encountered. 
In their characteristic form, however, they still retain an element 
of expansiveness. The patient believes that he owes millions to 
the King, that he is the King himself and cannot bear the weight 
of such responsibility, or that he has been suffering for thousands 
of years. Other delusions are more hypochondriacal in char- 
acter; there are tons of faeces in the abdomen, gallons of treacle 
in his chest, a harp in his throat, or his brain is too big for his 
skull. This curious mixture of depression and exaltation, 
melancholiac megalomania, is peculiar to general paralysis. 

Delusions of persecution are not uncommon. When they 
occur they lack the systematization characteristic of paranoia. 

The defect of reasoning power is well illustrated by a symptom 
first described, I believe, by Joffroy. Very shortly after the 
onset of the disease the patient is unable to do simple arithmetical 
sums on paper. He adds or multiplies from left to right; or 
perhaps in multiplying, say, 35 by 5, he will say, “ Five fives are 
twenty-five ’’ and put down 25 on the answer line, the ultimate 
appearance of the sum being: 


35 
# 


1525 


In some cases the patient gives up the attempt without putting 
pen to paper. 


440 MIND AND ITS DISORDERS 


The most striking changes take place in the domain of action 
or conduct. One by one, the patient loses control of his instincts. 
He ceases to attend to business, spends money recklessly and 
occupies the whole of his time out of doors playing games or 
motoring. Then he loses control of the sexual instinct, exposes 
himself or commits some indecent assault whereby he falls into 
the hands of the police. He makes absurd collections, sets to 
work to buy up all the grandfather clocks in London or buys a 
gramophone with thousands of valuable records: all the while 
he can afford none of these things. At this stage his friends 
begin to realize the true state of affairs and place him in an 
asylum or at least in such conditions as will put an end to his 
extravagance; but the collecting instinct continues—he hoards 
up all sorts of rubbish, old newspapers, worthless pebbles, buttons, 
odd playing-cards and chessmen. 

He becomes conceited, boastful and ambitious like a boy of 
fifteen, differing, however, from the latter in that he develops 
delusions of exaltation with regard to his prowess, capabilities, 
health, wealth and position. 

The eating instinct gets out of hand: he eats ravenously, even 
when he has only just completed a meal, and bolts potatoes 
and slices of meat whole. It is on account of this symptom 
that general paralytics in institutions for the insane are sys- 
tematically fed on mince. 

By this time the patient’s circumstances are usually such 
that the constructive instinct is not allowed full play; but he 
will often paint pictures which are surprisingly good considering 
that he has never put brush to paper before (thus demonstrating 
the advantage of self-confidence), or he may make attempts, 
usually not so good, to write music. He is full of schemes for 
benefiting humanity. He would make eggs from old oyster- 
shells, warm the poles by a system of hot-water pipes, tunnel 
the earth to Australia or take personally conducted tours round 
the planets. 

Then he becomes destructive, tears up his clothing or smashes 
windows or such articles of furniture as vases and flower-pots. 

Practical joking is not an uncommon feature about this stage. 

There is sometimes a transient return of the childish instinct 
of make-believe. For example, the patient will say that he is 
a Spanish onion, a poached egg or a pat of butter; not that he 
believes such absurdities, but merely in the playful spirit of 
make-believe. 

Before the general paralytic has lost control of these early 


INSTINCTS IN GENERAL PARALYSIS 441 


instincts degeneration of those more lately acquired has already 
begun. The out-of-door instinct has gone; he has no desire for 
hunting, fishing, shooting, motoring or out-of-door games. Simi- 
larly his sexual instinct disappears. He ceases to collect rubbish, 
or anything else for that matter. His boastfulness and conceit 
vanish and he forgets former delusions. He no longer evolves 
schemes, he becomes less destructive, loses the instinct of clean- 
liness, and is wet and dirty. 

The instincts to walk, stand and sit up disappear in turn and 
the patient reverts to the infantile age at which he crawled on 
all-fours. 

As with the instincts, so with the emotions. During the 
earlier stages of the disease the patient is excessively emotional; 
he laughs or weeps at nothing and a sympathetic word suffices 
to evoke a flood of tears. At other times he flies into a passion 
of anger without any adequate cause. In the latter stages, on 
the other hand, emotion disappears to such an extent that even 
the normal expression of the man’s face, largely dependent on 
the naso-labial furrows, is obliterated. 

Speech is markedly disturbed from the first. The vocabulary 
becomes more and more limited, proper names being the first 
to go, then common nouns, adjectives, verbs and interjections. 
Interjections are the last parts of speech to be lost and of these, 
“yes”’ and “no” are the very last. The first volitional word 
of the infant, “yes” is the last word uttered by the general 
paralytic, should the disease run its complete course without 
being cut short by some fatal intercurrent illness. 

Incoherence occurs in the majority of cases during some 
period of the disease. In some cases it is owing to the flight of 
ideas being too rapid for the patient’s language to keep pace 
with them; in others it is due to mental confusion. 

As a rule, the speech is slow, hesitating and often stammering. 
The patient has difficulty in finding the word he requires. The 
continuity of a sentence is frequently cut short by his forgetting 
the subject of his discourse and the most trivial interruption 
serves to produce such a result. It is due to an apprehension 
of this failing that some general paralytics exhibit a form of 
mutism, voluntary aphasia, from time to time. 

Defect of articulation, although a physical rather than a 
psychical symptom, is best considered in this place. The general 
difficulty of articulation leads to stuttering and the elision or 
repetition of syllables and words. On account of tremor and 
loss of control of the muscles of articulation the consonants are 


442 MIND AND ITS DISORDERS 


blurred and uttered in a quivering manner. Various phrases, 
some of which are unnecessarily difficult, have been devised as 
special tests for the articulation of general paralytics. The 
following are a few examples: 

‘“ Around the rugged rock the ragged rascal ran his truly rural 
race.” 

“ The Irish constabulary extinguished the conflagration.” 

““ She stood at the door of Burgess’s fish-sauce shop, welcoming 
him in.” 

“She sells sea-shells and shaving soap.”’ 

“ Biblical commentators.” 

“Trish artillery.’’ ‘‘ Statistical tables.’ “ Irretrievable.”’ 
“ Conservative.”’ “‘ British Constitution.”’ 

Some of these sentences are also memory tests, for the patient 
is often found to be incapable of remembering the whole of one 
of the longer sentences. 

In reading aloud, the general paralytic omits some words, 
interpolates others and modifies yet others to a slight extent, so 
that the writer’s meaning is misinterpreted. 

Written language suffers in much the same way. Letters and 
words are elided or reduplicated. The patient becomes confused 
in the construction of long sentences and seldom attempts, for 
example, a dependent sentence with a possessive pronoun. As 
a result, all his correspondence consists of short sentences, then 
disjointed phrases, and lastly, disjointed words. 

In writing to dictation he omits words, interpolates others 
which are not dictated to him and modifies others in much the 
same Way as in reading aloud. 

The calligraphy becomes puerile: the lines are not straight, but 
undulating; the individual letters are separated from one another 
and occasionally show evidence of hand tremor. As the disease 
advances the writing becomes larger so that a dozen words suffice 
to fill a sheet of notepaper, apart from smudges and blots, which 
are an invariable accompaniment. 

After a short preliminary period of insomnia during the early 
stages the patient is liable to fall asleep at all hours of the day, 
even while he is in the midst of a most important piece of busi- 
ness, and he sleeps heavily at night. As the disease advances, 
persistent motor restlessness becomes a prominent symptom 
during the day and he again sleeps badly at night. This 
insomnia persists until the later stages, when sleep once more 
becomes excessive. 

The general paralytic is a very suggestible individual, and as a 


STAGES OF GENERAL PARALYSIS 443 


rule is easily managed, especially by strangers. His volition is 


so weak that with tactful management one can always lead or 
thwart him. 


Stages.—Apart from the prodromal stage, in which the patient 
suffers from occasional headaches, tinnitus aurium, formications, 


(FE 
Southark, Loni. 
moet | 
ket 
J shawhee Dikicypls erme 
» Lote wih me Lu Loni 


€ ? : ~ 
Fic. 68.—LETTER BY A GENERAL PARALYTIC. 


Joffroy’s symptom is illustrated in the last few lines. The patient was 
formerly a learned scientist. 


local flushings and pallors, lapses of memory and partial in- 
capacity for business matters, general paralysis is usually divided 
into three stages, which cannot, however, be sharply distinguished 
from one another. 


444 MIND AND ITS DISORDERS 


During the first stage the patient loses flesh, looks ill and the 


various physical signs characteristic of the disease become estab- 


lished. Mentally, this stage is characterized by progressive loss 
of will-power, loss of control of the instincts in the order already 
described, emotionalism, inability to keep voluntary attention 
fixed on a subject, and tendency to the formation of delusions. 
The patient is absent-minded and forgetful of duties, appoint- 
ments and even meals; but he stands the ordinary memory tests 
fairly well. During the first half of this stage he is liable to be 
excessively drowsy; in the latter half insomnia is the rule. 

During the second stage the patient becomes unhealthily fat, 
plethoric and bloated. The naso-labial folds disappear, the face 
becomes expressionless and the various physical signs well 
marked, especially difficulty of articulation. The beginning of 
this stage is marked by deterioration of the latest acquired 
instincts, the other instincts being subsequently lost. Of active 
attention there is none, and now instinctive attention gradually 
disappears. There is no tendency to the formation of new 
delusions and former delusions become forgotten. The memory 
will no longer stand the ordinary tests, and little by little, it 
becomes obliterated. Sleep becomes again excessive, especially 
during the day. It is during this stage that fits are especially 
liable to occur. The second stage of the disease has accordingly 
been called the “ fat, fatuous and fitty ” stage. 

Paralysis of the limbs now sets in and the patient enters the 
third stage. He is bedridden, wet, dirty, and oblivious of his 
surroundings. Mentation is reduced to the very lowest ebb, 
and ultimately all that remains is the instinct (or reflex) to take 
food from a spoon when it is put to his lips, the patient’s condi- 
tion being comparable with that of a newborn babe. Such 
food may consist of soft solids for some weeks or even months; 
but the time comes when liquid food only can be swallowed. 
About three weeks later the deglutition reflex is completely 
abolished and death from inanition follows in a couple of days. 
Rather, however, than allow a patient to die from inanition, I 
have him tube-fed to the last. Life may sometimes be prolonged 
in this way for another six months. 


Clinical Varieties. 


Demented Form.—This form is characterized by progressive 
mental deterioration without any great excitement, exaltation or 
depression and without prominent hallucinations. 


we — 


VARIETIES OF GENERAL PARALYSIS 445 


The patients lose their former energy and capacity for work, 
become forgetful of details and commit errors of judgment. 
They have some insight into their condition, and therefore seek 
medical advice of their own accord. Not infrequently it happens 
that a patient of this nature will enter an institution for the 
insane as a voluntary boarder. 

Deterioration of volition, instinct, emotion and memory take 
place in the manner already described. The physical signs run 
the usual course. 

Expansive Form.—This includes the cases in which delusions 
of exaltation predominate, in which the patient, in spite of his 
tremulous articulation and tottering gait, declares that he never 
felt better in his life (euphoria), is stronger than he ever was, is 
able to lift tons and perform unprecedented athletic feats, is 
the greatest poet, author, musician, artist, orator, financier and 
crowned head that ever lived. So enormous are his supposed 
possessions that he is generous to a fault; it is impossible to keep 
him supplied with tobacco, for he distributes it freely to all the 
other patients in the ward. Benevolence is one of the most 
striking characteristics, not only of this form of the disease, but 
of general paralysis as a whole. 

There is another variety of the expansive form of the disease, 
in which the patient enjoys a feeling of general well-being and 
recounts with self-satisfaction all the beneficent and other pleasing 
incidents of his past life, forgetting all unpleasant details; but he 
never develops such bizarre delusions as those above enumerated. 

Maniacal Form.—Here we have to deal with cases which, to a 
casual observer, present the characteristics of a severe attack of 
acute mania. The patient is wildly excited, noisy, dirty, destruc- 
tive and dangerous. In addition he exhibits all the characteristic 
signs of general paralysis—immobile pupils, exaggerated or 
absent knee-jerks, tremors etc. 

These cases are especially liable to remission. The patients 
make an apparently complete recovery; the excitement passes 
off, tremors disappear, and I have seen cases in which even the 
light reflex and knee-jerk returned, both having been absent 
during the attack of excitement. Subsequently the patient has 
several similar attacks which leave him more and more demented. 
It may be eight or ten years before he requires permanent asylum 
care and his disease reaches its fatal termination. In some of 
these cases expansive delusions may be associated with the 
attacks of motor excitement. 

It happens occasionally that the excitement attains the 


446 MIND AND ITS DISORDERS 


intensity and severity of acute delirious mania, with high tem- 
perature, frequent pulse, sordes on the teeth and inability to 
retain food, the patient passing rapidly into a typhoid state and 
dying of exhaustion (galloping general paralysis). 

Depressed Form.—This variety is almost as frequent as, if not 
at the present day more frequent than, the expansive form. The 
patient may have delusions of past wickedness and assert that — 
his soul is lost or that he is ruined; but hypochondriacal delusions 
are by far the commonest in this variety of the disease. His 
throat or bowels are obstructed or on fire, his body is made of 
glass and liable to fall to pieces if any attempt at movement be 
made; he is so small that he weighs but a few ounces and can 
get through the keyhole, so big that he cannot pass through 
the doorway or he is dead and putrefying. As already stated, 
many of these patients indulge in such grotesque exaggeration 
of their affliction that there results that curious mixture of de- 
pression and exaltation which is peculiar to general paralysis. 
As with the maniacal form, remission is not uncommon in this 
variety. 

A few of the depressed cases develop delusions of persecution. 
Such delusions are unsystematized and unlikely to lead to errors 
in diagnosis. 

Stuporose Form.—This is not a common variety. When it 
occurs volition, instinct and emotion are in abeyance from the 
first. The patient sits unoccupied in one position the whole dav 
long, never engages in conversation and is “‘ wet and dirty’. He 
is not depressed; the stupor gradually gives place to dementia, 
the patient giving little or no evidence of mentation during the 
whole course of the disease. 

Circular Form.—This variety is also uncommon. There may 
be an alternation of periods of excitement and depression with or — 
without intervening periods of quietude. 

Convulsive Form.—In some cases convulsions are the chief 
clinical feature of the disease. It occasionally happens that a 
person, suffering from hitherto unsuspected general paralysis, 
suddenly has a batch of fits (status epilepticus) with hyper- 
pyrexia and dies. This may be regarded as one form of galloping 
general paralysis. In other cases the patient has frequent attacks 
of status epilepticus or frequent isolated convulsions and the 
disease runs a rapidly fatal course. Under such circumstances he 
is said to be suffering from the convulsive form of the disease. 

Female Form.—In women general paralysis is usually of the 
demented or depressed variety without much tendency to the 


VARIETIES OF GENERAL PARALYSIS 447 


formation of delusions. Krafft-Ebing and Regis ascribe this 
peculiarity to the relative poverty of ideation in women. Re- 
missions are rare and the disease runs a more chronic course than 
in males. 

Juvenile Form.—Many cases have been recorded of general 
paralysis occurring in congenital syphilitics during the second 
decade of life. The physical signs differ in no way from those 
of other cases; but the mental symptoms are somewhat different 
on account of the patient’s mental evolution being, at the begin- 
ning of the disease, yet incomplete. The mental symptoms of 
the earliest cases accordingly resemble those of imbecility rather 
than insanity. Remissions do not occur in this variety. 

Tabetic, spastic and amyotrophic forms are recognized by the 
French school. Apart from the spinal complications, these forms 
only differ from ordinary general paralysis in that there is an 
increased tendency for the disease to be of the depressed variety. 
It is said that, should general paralysis develop in a patient who 
has suffered for some years from the results of spinal lesions, 
there is amelioration of the spinal symptoms. 

Prognosis.—Left untreated, the natural prognosis of general 
paralysis is grave. Most of the cases prove fatal within three 
years; but it is not sufficiently recognized that a few completely 
recover. The galloping forms of the disease run their course in 
two or three weeks or even less. Three to six months is the 
usual time for the convulsive form. Cases with alternative 
excitement and depression seldom last much longer than twelve 
months. Expansive cases usually reach their fatal termination 
within two years. In the demented form the cases last rather 
longer, about two and a half years as a rule, and the depressed 
cases last from three to three and a half years. The outlook 
is much more favourable in the excited cases, because these are 
the most liable to remit. It is not at all uncommon for such 
patients to live six to ten years before the fatal termination is 
reached and, during a considerable portion of this time, they may 
be well enough to do useful work. Many cases of apparent 
recovery have been recorded in this variety of general paralysis. 
On the other hand, excited cases which do not remit run a rapidly 
fatal course. 

Some depressed cases are also liable to remission, but this is 
not so common as in cases of excitement. 

In tabo-paralysis and in women the course of the disease tends 
to be prolonged. 

The proportion of cases in which remissions occur, as given 


448 MIND AND ITS DISORDERS 


by different writers, varies very considerably. Cotton analyzed 
127 cases of general paralysis in which the diagnosis was con- 
firmed by lumbar puncture and found that spontaneous remis- 
sions were observed in only 4 per cent. Mapother and Beaton 
give the proportion as 7 to 8 per cent., with an average duration 
of eleven months. Dr. Noble, one of the House Physicians at 
the Bethlem Hospital, kindly investigated for me the results of 
a hundred consecutive cases occurring during the later nineties, 
when no specific treatment was adopted, and he found that 
remission occurred in 14 of them (14 per cent.). 

As a rule the duration of these spontaneous remissions is from 
six months to a year or so, but a few cases are found in literature 
in which remissions lasted for four or five years, or even con- 
siderably longer than this. An illustration of this is the case 
of Tuczek, in which the patient was first attacked by general 
paralysis at the age of thirty-six, the mental symptoms dis- 
appearing two years later. This was followed by a remission 
of twenty years, after which symptoms of general paralysis 
again recurred, the patient dying at the age of fifty-eight. Nissl, 
who made the post-mortem examination, found the changes in 
the cortex characteristic of dementia paralytica. Another case 
of this kind is reported by Dr. G. M. Robertson. The patient, 
who lived thirty years after the onset of the disease, showed 
typical symptoms for the first five years. Then followed a 
remission of fifteen years, and after another attack, a second 
remission of seven years, the symptoms reappearing during the 
last two years of life. 

It has frequently been observed that remissions are liable to 
occur in patients who have been attacked by an acute illness, 
especially an acute specific fever. It occasionally happens that 
the patient develops a large phlegmon, perhaps in one thigh. 
When this is opened or bursts spontaneously a large quantity 
of muco-sanious fluid escapes and the progress of the disease is 
arrested. Vallon and Doutrebente have published two such 
cases, and I have heard of one other in Vienna. 

The prognosis above given for general paralysis refers to un- 
complicated cases which have not been treated by certain modern 
methods, to be presently described, which give some hope of 
our being able to do more for this disease thari has been achieved 
in the past. The possibility of death from accidents, complica- 
tions or intercurrent illness must always be borne in mind. In 
any form or at any stage of the disease life may be suddenly cut 
short by an attack of status epilepticus or the patient may acci- 


DEATH OF GENERAL PARALYTICS ys: 


dentally choke himself with a bolus of food; and, although 
suicide is an uncommon mode of death in general paralysis, 
it is liable to occur in depressed, especially hypochondriacal, 
cases. 

Broncho-pneumonia may be set up by food passing into the 
bronchi; this is especially liable to happen to those patients who 
refuse food and have it forced upon them with a feeding-cup 
instead of an cesophageal tube. 

Unless care and cleanliness are used in the treatment of those 
who suffer from retention of urine and require the passage of a 
catheter, the course of the disease may be shortened by cystitis, 
suppurative nephritis and general septicemia. Similarly, unless 
care be taken in the prevention and treatment of bedsores, an 
acute fatal septicemia may develop. 

A considerable number of general paralytics die of phthisis and 
ulcerative colitis, which appear to be endemic in many of our 
large public asylums, especially, as it seems, in those of fairly 
recent construction. The tubercular opsonic index of general 
paralytics is subnormal. Lastly, the disease may be complicated 
by any ordinary intercurrent affection, such as pneumonia. 

Treatment.— Until recently there were so many methods for 
attempting to cure general paralysis that we could only conclude 
that the problem had not yet been solved, although there were 
people who claimed a certain amount of success for each one 
of them. It may be said at once that ordinary antisyphilitic 
treatment with mercury, iodide of potassium, salvarsan or one 
of its substitutes is of no avail because these drugs do not reach 
the seat of the disease. They cannot pass the barrier of the 
choroid plexuses, which acts as a kind of filter, and they therefore 
fail to enter the cerebro-spinal fluid. 

A specific attempt to kill the spirochetes in the cerebral tissue 
has been made in a large number of ways. Probably the earliest 
drug to be used for this purpose was hexamine. 

Hexamine (10 to 20 grains), given three times a day in com- 
bination with twice the quantity of acid sodium phosphate, 
appears in the cerebro-spinal fluid as a weak solution of formalin 
(about x in 20,000). Apparently it does not kill the spirochetes 
as a rule, but it has the advantage of killing other micro-organisms 
usually present in the cerebro-spinal fluid of general paralytics 
(the diplococcus of Porter Phillips and the diphtheroid of Ford 
Robertson, for example), and thus of preventing convulsions of all 
kinds. Moreover, in my experience about 25 per cent. of general 
paralytics treated with hexamine haye remissions and 17-6 per 

29 


450 MIND AND ITS DISORDERS 


cent. do not relapse or I have not heard of them again. I cannot 
but conclude that some of these cases are recoveries. 

Alcohol is another drug that finds its way past the barrier of 
the choroid plexuses and enters the cerebro-spinal fluid, and I 
have noted in three or four cases of general paralysis marked 
improvement after an alcoholic bout. For these reasons I allow 
alcohol (preferably brandy-and-soda) to general paralytics after 
they have started a course of hexamine, in spite of the fanatical 
teetotal propaganda of the present day, and have been gratified 
with the rapid improvement in many cases and the number of 
remissions. Some of these may prove to be recoveries, but the 
least that can be said for such treatment is that no general 
paralytic patient of mine ever has convulsions. 

More recently tryparsamide, a drug which has been used since 
1919 for the treatment of trypanosomiasis (sleeping sickness)—a 
disease in many ways analogous to syphilis—has been used for 
general paralysis in America and at the Maudsley Hospital with 
very promising results. The success of this drug is due to the 
fact that it passes the choroid plexuses, and according to the 
published results it induces a remission in about two-thirds of 
the cases; but it is, of course, too soon to say whether these are 
cures. It is unfortunate that up to the present tryparsamide 
can only be obtained from the Rockfeller Institute, whose supply 
is naturally somewhat limited. 

In the last edition details and criticisms were given of the 
many methods which have been employed in attempts to treat 
the disease more specifically by introducing salvarsanized serum 
or mercurialized serum or both into the cerebro-spinal fluid, either 
by lumbar puncture or into the cranial cavity by operation; but 
all these have since been practically abandoned in favour of 
the malarial treatment presently to be described. 

Another method of treating general paralysis is based on an 
entirely different principle. It owes its origin to the observation 
that remissions are especially liable to occur after an attack of 
some acute specific fever and, in years gone by, physicians used 
to attempt to produce suppuration artificially. Ointment of 
tartarated antimony used to be rubbed into the scalp, the treat- 
ment being sometimes continued until small pieces of bone were 
detached from the skull; but it is scarcely necessary to say that 
such an extremely energetic procedure was not by any means 
devoid of danger to the patient. 

It is obvious that it would involve too great a risk deliberately 
to infect a general paralytic with, for example, enteric fever for 


TREATMENT OF GENERAL PARALYSIS 451 


the purpose of inducing a remission, or even a possible cure; but 
Pilcz of Vienna hit upon the idea of injecting doses of tuberculin 
with the object of exciting a febrile attack. How such febrile 
attacks effected the desired result is not definitely determined, 
but the opinion of most physicians was that the accompanying 
pleocytosis served to combat any organism which might be 
responsible for general paralysis. According to the experience 
of syphilologists the entrance of the causative agents of septic 
disease tends to inhibit the growth of the spirocheete, and it 
therefore appears possible that the toxic products of such bacteria 
might form a combination against those responsible for general 
paralysis. As the tuberculin treatment has not survived we 
need say no more about it in this edition. 

The malarial treatment owes its inception to Wagner-Jauregg 
of Vienna, where it has been tried since 1917 on the largest scale. 
In 1925 Gerstmann published the results of the cases treated 
there between 1917 and the end of 1922, and they are given in 
the following table, which was published in a paper by Professor 
Yorke in the Lancet of February 27, 1926: 


RESULTS OF MALARIAL TREATMENT IN 400 GENERAL PARALYTICS AT 
VIENNA, COMPILED FROM INFORMATION SUPPLIED BY GERSTMANN 


(1925). 
| | Slight Change, 
Date Treated. Wee Local Compile | ita: no Change, 
) Cases, | Remission. | Remission, | or Dead. 
IQI7 re ae ie 9 4 | 2 3 
I9QIQ—-1920 .. me ae 25 8 3 | 14 
1920-1921 .. - Be 116 38 14 | 64 
I92I-1922 .. ie ay 250 83 40 | 127 
FF OtAL. s ~ . 400 133 (33°95) 59 (15%)| 208 (52%) 
| 


From this it may be gathered that the malarial treatment cures 
one-third of the patients. The earlier the patient is treated the 
more successful is the result likely to be, while one cannot 
hope for anything like a cure in patients who have suffered from 
the disease for more than one year. 

The treatment consists of infecting the patient with simple 
tertian malaria (Plasmodium vivax). This is usually done by 
injecting infected blood into a vein of the patient, but another 
method is to allow infective anopheline mosquitoes to bite the 


452 MIND AND ITS DISORDERS 


patient. Arm-to-arm inoculation is easily carried out in mental 
hospitals, but there is a little difficulty in treating isolated cases 
because the malarial parasite lives only a very short time 17 v1tro. 
Poetzl of Prague, however, gives the following technique for 
preserving the blood: ‘‘ On withdrawal the blood containing the 
parasite is defibrinated by shaking it up with glass beads in a 
flask or test-tube under sterile conditions; the fluid, containing 
corpuscles and parasites, is transferred to another sterile tube, 
and this is kept in the ice chest or, for immediate despatch, 
packed surrounded by ice in a thermos flask.’’ Dr. R. M. Clark 
of the Lancashire Mental Hospital, Whittingham, Preston, 
states that the blood so prepared is effective for at least sixty- 
five hours, and he does not regard even this time as the outside 
limit; 2 c.c. of such blood are sufficient to give the patient 
malaria. After an incubation period of usually one to three 
weeks, he has his first malarial attack, lasting about ten 
hours. Typically the subsequent attacks should occur every 
other day, but one often finds irregularities in the periodicity. 
It is customary to allow the patient to have twelve such 
attacks. 

No medicine should be given. Adherence to this rule some- 
times requires a great deal of moral courage, for sometimes the 
paroxysms may be very severe and the patient alarmingly ull. 
One does not wish to have it on one’s conscience that the patient 
has died of malaria; on the other hand, to stop the treatment 
too soon would spoil the whole procedure and result in failure to 
cure the general paralysis. Moreover, it must not be forgotten 
that the patient cannot be infected again until after the lapse 
of many months. Hyperpyrexia during the paroxysm should 
be controlled by cold sponging. After the twelfth malarial 
paroxysm, or before this if the patient’s life is in danger, quinine 
is administered in solution, 5 grains every four hours for three 
or four consecutive days. This cures the malaria, which is rather 
surprising when we consider the comparative difficulty of curing 
ordinary tropical malaria. It is said that the prognosis is much 
better when the clinical manifestations clear up before the changes 
in the cerebro-spinal fluid than when this sequence of events 
is reversed. 

Donath, and subsequently Fischer, Lépine and others, on the 
assumption that the leucocytosis associated with infective con- 
ditions might possibly have a favourable influence on general 
paralysis, adopted the expedient of using a drug which is 
known to have the effect of inducing a well-marked hyper- 


TREATMENT OF GENERAL PARALYSIS ADS 


leucocytosis, viz., nucleinate of soda. They use the following 
solution :— 


Sodium nucleinate  .. Sa a ie 2) patta: 
Sodium chloride nae a Pr ms 2 parts. 
Sterilized distilled water ig he .. 100 parts. 


Donath recommends seven injections of this solution sub- 
cutaneously at intervals of five days. In the first place 50 c.c. 
are injected, and on subsequent occasions 100 c.c. A febrile 
reaction follows, and if this fails to occur larger doses should 
be given. Donath states that he has given as much as 180 c.c. 
in a single dose. With this treatment he obtained a remission 
in 13 of 36 cases (about 35 per cent.). Fischer obtained re- 
missions of considerable duration in 4 of 22 cases, and is of 
opinion that the juvenile type of general paralysis is especially 
suitable for this mode of treatment. Purves Stewart also 
obtained more or less prolonged remissions in several cases. 
At one time I seemed to have some success from the use of 
nucleinate of soda, but more recently I have lost confidence 
in it. 

The great disadvantage is the enormous quantity of fluid 
which it is necessary to inject, and nucleic acid in a more con- 
centrated solution has been suggested as a substitute. I have 
tried it, but cannot say that it proved successful. In fact my 
experience was somewhat curious; the leucocyte count went 
down and stopped down. 

Pilcz has made the observation that, although a good pleo- 
cytosis is usually induced by initial doses of a leucocytosis- 
producing substance, the organism soon becomes accustomed 
to them and no leucocyte reaction takes place, even though a 
rise of temperature occurs. He accordingly modified his original 
method by varying the substance used. On one day he injects 
0°02 grm. of succinamide of mercury, on another 0°005 grm. 
of tuberculin, perhaps increasing the dose to a gramme. This 
is varied with injections of dead cultures of staphylococci, 
streptococci, nucleinate of soda, salvarsan, and so on. I know 
of no published results of this method, but it seems to be the 
general opinion that it is more successful than the use of tuber- 
culin alone. 

Apart from any attempted specific treatment, the general 
paralytic should be placed in healthy surroundings and induced 
to live in the open air as much as possible, just like a tubercular 
patient. He must be well fed on a liberal, nutritious, minced 
diet with plenty of milk. 


454 MIND AND ITS DISORDERS 


Insomnia is not usually a troublesome symptom in this disease, 
but, should it occur, and be serious enough to demand drug 
treatment, isopral should be given. This drug appears to have 
a specific action on the disease, perhaps because it is an alcohol. 

Motor excitement may be allayed by prolonged baths as in 
the case of an ordinary attack of acute mania. Any tendency to 
convulsions may be combated with bromide of potassium, chloral 
hydrate or, in status epilepticus, with a hypodermic injection of 
morphia. A drop of croton oil is sometimes useful in cutting 
short an apoplectiform attack in patients who are not being 
treated with hexamine. 

Retention of urine should, of course, be treated by the regular 
use of a clean aseptic catheter. Bedsores are to be prevented 
by keeping the patient clean and dry. Should they occur in 
spite of precaution, they must be first rendered aseptic by the 
use of turpentine fomentations and subsequently painted with 
several layers of the compound tincture of benzoin. 

Morbid Anatomy.—The most striking feature of the morbid 
anatomy of general paralysis is the diffuseness of the lesions. 
Almost every organ of the body, on careful examination, shows 
some degenerative change, so that no doubt exists in the mind 
of the pathologist that the disease is of toxic origin. 

The calvarium, on removal, is found to be thickened, the diploé 
being obliterated (hyperostosis), especially in its anterior part; 
as a result, it is two or more ounces heavier than is natural. 
Much less frequently the bones of the skull are thin and the diploé 
well marked (rarefying osteitis). Hyperostosis is not often 
observed elsewhere. Rarefying osteitis is occasionally observed 
in the long bones. In such cases an abnormal brittleness of the 
bones may have been a clinical feature during life and at the post- 
mortem the ribs may be broken like a biscuit between the fingers. 

There is almost invariably hypostasis and cedema of the lungs 
and there may be foci of bronchopneumonia. Well-marked 
atheroma aorte occurs in about 35 per cent. of the cases and 
slight atheroma or endarteritis in about 45 per cent. In the 
heart atheroma of the mitral valve is fairly common; the muscle 
is pale and flabby and, if a portion be teased out in osmic acid, 
fatty degeneration can usually be determined under the micro- 
scope. Some fatty degeneration can frequently be observed in 
like manner in the liver and there is occasionally some cirrhosis. 
Slight parenchymatous nephritis, or at least granular degenera- 
tion of the renal cells, is also common. D’Abundo states that 
vesical and prostatic lesions are of frequent occurrence. 


BONE CHANGES IN GENERAL PARALYSIS 455 


But the most striking lesions of all are those of the nervous 
system and meninges. The dura mater is thickened and adherent 
to the calvarium, especially along the sagittal suture. In some 
cases it is lined with a false membrane varying in thickness up 
to 1 inch and consisting of an organized clot of blood which 
has escaped from degenerate vessels of the dura mater. The 
membrane grows in thickness owing to degeneration and rupture 
of newly formed vessels in the membrane, thus forming a fresh 
layer of blood which in turn becomes organized into another layer 
of membrane. This process, which is known as “‘ pachymenin- 
gitis hamorrhagica interna’’, may be repeated several times. 
Calcareous plates are sometimes found in the substance of both 
the cranial and spinal portions of the dura. The arachnoid is 
thickened and opalescent. Where it bridges over sulci it shows 
milky spots and streaks along the course of small vessels. The 
Pacchionian bodies are increased in number and hypertrophied. 
The pia mater is thickened and cedematous, its meshes being 
distended with pale yellowish fluid. There is also a great excess 
of cerebro-spinal fluid about the base of the brain and in its 
dilated ventricles, partly due to an increased production, as 
indicated by the high pressure observed when a lumbar puncture 
is performed, and partly contingent upon the loss of cerebral 
substance by wasting. 

The brain commonly weighs about 44 ounces or less instead 
of the normal weight, 48 ounces (male). On stripping the pia 
mater from the convolutions and dissecting the brain much fluid 
escapes, so that it commonly happens that the dissected brain 
weighs 3 ounces less than on removal from the body. The left 
cerebral hemisphere weighs less than the right, thus giving evi- 
dence that it, being the more voluntary, more highly evolved and 
therefore more unstable hemisphere, suffers from the morbid 
process more than the right hemisphere, its inferior brother, 

On attempting to strip the pia mater from the cerebrum small 
portions of brain substance from the summits of the convolutions 
remain adherent to the membrane, leaving small lacerated areas 
on the cortex (decortication). This feature is absolutely charac- 
teristic of a general paralytic brain, provided that the interval 
between death and the autopsy is not much prolonged. It 1s 
said by some to be due to rapid post-mortem softening of the 
grey matter. 

The convolutions are wasted and the sulci widened in con- 
sequence and the grey matter is seen on section to be thinner 
than natural; these characters are most marked in the anterior 


456 - MIND AND ITS DISORDERS 


half of the cerebral convexity. The white matter on section is 
shiny owing to excess of fluid; puncta cruenta are well marked 
on account of dilatation of vessels and the perivascular spaces 
are sometimes visible to the naked eye in the more superficial 
parts of the white matter. Some cases, which during life have 
been subject to apoplectiform attacks, are found at the autopsy 
to have small foci of softening in the optic thalamus. 

The ventricles are dilated and their ependyma frequently © 
presents a granular, frosted aspect which has been compared 
to the appearance of the ice-plant. This is best seen, when 
present, in the floor of the fourth ventricle. 

Histological Changes.—Since the sequence which an author 
adopts in describing the microscopical appearances depends upon 
his own interpretation of the changes, a preliminary considera- 
tion of various views as to the nature of the disease may not be 
out of place. 

For many years pathologists have ranged themselves on 
opposite sides, according to the view they hold of general para- 
lysis being either a primary inflammatory or a degenerative 
change in the cerebral cortex. Such a discussion need not detain 
an unbiassed observer, for it resolves itself at bottom into a 
mere quibble about words. If by inflammation we mean “ the 
reaction of a tissue to injury which is insufficient to destroy its 
vitality ’’, then, as we shall see, inflammatory processes are 
certainly at work in the cortical meninges, neuroglia and blood- 
vessels. On the other hand, we shall see also reason for supposing 
that the cortical neurons may undergo primary degeneration, 
although at the same time subjected to processes causing secon- 
dary degeneration. Our contention is, then, that both schools 
of pathologists are right. 

The question whether the neural degeneration is primary or 
secondary to changes in the glia, bloodvessels and perivascular 
canals may be similarly answered. It is unlikely that such 
unstable elements of the cortex as the neurons would escape 
primary degeneration while neighbouring mesoblastic elements 
are suffering from the morbid influence of a toxic environment. 
On the other hand, it will be seen that the morbid changes in the 
mesoblastic elements are more than sufficient to interfere with 
the nutrition and to cause secondary degeneration of the neural 
elements. 

The earliest change takes place in connection with the vascular 
(blood and lymph) systems of the cortex. The vessels of the 
pia become distended with blood and there is nuclear prolifera- 


PLASMA CELLS 457 


tion in the walls of the arterioles and perivascular canals with a 
copious formation of new capillaries. There is overgrowth of 
the endothelial cells of the capillaries and, on their adventitial 
sheath, which normally consists of elongated cells, there develops 
a regular felt-work of similar cells having special characters 
(plasma-cells). In this situation they are peculiar to general 
paralysis. They lie at right angles to the cortex; they have 


Fic. 69.—A SMALL CorRTICAL VESSEL IN THE OCCIPITAL LOBE OF A 
GENERAL PARALYTIC, SHOWING TYPICAL PLASMA CELLS (x) UPON IT. 


Note the oblong, angular or oval shape with a clear space in the cyto- 
plasm and the laterally situated nucleus with its darkly stained chromatic 
bodies. (X800.) [Negative kindly lent by Dr. John Turner.] 


traces of protoplasm at both ends and a clear centre containing 
very minute granules which stain with methylene blue and the 
nucleus is seen in transverse sections to occupy an eccentric 
position. By some these “‘ plasma-cells ’”’ are regarded as altered 
leucocytes, by others as derivatives of glia-cells. The latter view 
seems untenable, because similar cells may be found in the peri- 


458 MIND AND ITS DISORDERS 


vascular tissues in almost any focus of chronic inflammation in 
any part of the body. Nor is the view that the plasma-cells are 
altered leucocytes easy of acceptance, for they bear no resem- 
blance to leucocytes. Their resemblance to normal cells of the 
adventitial sheath is, on the other hand, somewhat striking, 
and suggests a more probable source of origin. A peculiar rod- 
shaped cell is also seen in the cortex, Nissl’s Stdbchen cell, which 
Alzheimer believes to be derived from cells of the bloodvessels — 
and Mott regards as collapsed capillaries in section. 


seperate 
A 5 Fe 


a a? eb ee eee 


nce Ea inci i hd eee MNES Sn es a 


Fic. 70.—A GLIA OR SPIDER CELL FROM THE CORTEX OF A GENERAL 
PARALYTIC’S BRAIN. 


The stout, vascular fibres ending in fan-like expansions by which they 
are attached to the walls of the bloodvessels are well shown. A film 
preparation. (X600.) [Negative kindly lent by Dr. John Turner.] 


Meanwhile there is diapedesis of leucocytes into the peri- 
vascular spaces, which become further choked by mast-cells and 
hyaline débris, probably derived from degenerate nerve-cells. 
Mast-cells are also present, connective tissue leucocytes with 
basophile granules. This choking of the perivascular canals, 
associated with thickening of the capillary walls, causes great 
interference with nutrition of the neural elements of the cortex. 

The neuroglia undergoes proliferation. The spider-cells are 
especially numerous, not only in their normal situations, but also 


SPIDER CELLS 459 


in the deeper layers of the cortex where normally they are not 
to be found. Some of the new-formed spider-cells become three 
or four times the normal size (monster-cells). 

Many of the cortical nerve-cells become strangled by the over- 
growth of neuroglial fibres. Overgrowth of the neuroglia is also 
responsible for the granular appearance of the ventricles already 
described. Karyokinetic figures. are occasionally observed in 
the nuclei of the glia-cells. 

It has been demonstrated by Dr. Bevan-Lewis that some of 
these spider-cells in the neighbourhood of a perivascular canal 


be 7 a 3 


We 


Fic. 71.—SPIDER CELLS IN THE INNERMOST CORTICAL LAYER FROM THE 
BRAIN OF A CASE OF CHRONIC INSANITY, SUBJECT TO EPILEPTIFORM 
SEIZURES AND WITH A PROBABLE HISTORY OF ALCOHOLIC INTEMPER- 
ANCE. 


a=Spider cell, with many branches, one of which is attached to a vessel; 
b=vascular attachment with fan-shaped expansion on vessel (the cell to 
which this branch belongs is out of the field of section}. (Xx600.) [Nega- 
tive kindly lent by Dr. John Turner. ] 


have one process longer than the others, with its end expanded 
and closely applied to the perivascular lymphatic. It has been 
inferred that such cells assume a migratory function and serve the 
purpose of scavengers by absorbing the effete products of neural 
degeneration and excreting them into the perivascular spaces. 
As a result of these three morbid processes (intoxication, dis- 
turbance of nutrition by interference with the circulation of 


460 © MIND AND ITS DISORDERS 


blood and lymph in the cortex, strangulation by the overgrowth 
of neuroglia) there is extensive destruction of the cortical neurons. 
The earliest destruction of nerve-cells usually takes place in the 
physical basis of the most highly specialized functions, especially 
in the motor centre for speech, but it is best studied in the large 
cells of Betz in the mid-Rolandic area. 

Chromatolysis is the first change: the chromatic granules 
become powdery and ultimately disappear. The fibrous achro- — 
matic substance then suffers (achromatolysis) and the nucleus 
loses its central position, becomes displaced by the periphery and 
finally extruded. The nucleus, which normally remains un- 
stained in preparations by Nissl’s method, takes the stain in 
degenerate nerve-cells; while the nucleolus does not take the 
stain as well as in a normal specimen. 

In sections prepared by Cox’s method (see Appendix A) it 
may be seen that there is a deficiency of gemmules on the proto- 
plasmic processes (dendrons) and that they are replaced by 
localized thickenings or varicosities. 

Lastly, on the death of the cell-body there is degeneration of 
its axon. Degeneration of the pyramidal fibres may be demon- 
strated in the white matter and in the spinal cord by Orr’s modi- 
fication of Marchi’s method. According to Orr and Cowen, 
the degeneration is most marked in patients who have during 
life suffered from convulsions. 

The tangential layer of fibres is atrophied. 

Bianchi mentions atrophy of the nerve-fibres of the cere- 
bellum and Roecke has described an increase of the fibres of 
Bergmann in the molecular layer of that organ. 

More important than all these observations is that of Noguchi, 
confirmed by many pathologists, that spirochetes can be demon- 
strated by various methods to be present in large numbers in 
the substance of the cortex cerebri, mostly at the frontal and 
temporo-sphenoidal poles. The best place to find them is on 
the mesial surfaces of the frontal lobes, especially where these 
are adherent to one another. The organisms are distributed 
in groups of hundreds, between which groups not a single spiro- 
chete is to be found, so that one need not be discouraged by 
failure to demonstrate them in the first preparation. 

All the cranial nerves show degenerative changes by the Marchi 
method, many of the medullary sheaths being studded with little 
black patches. Vassale has pointed out that degeneration of 
this nature is characteristic of a primary lesion of the fibres 
from the direct action of a toxin and is not of the nature of a 


CEREBRO-SPINAL FLUID AGT 


Wallerian degeneration dependent upon lesions of the cranial 
nuclei. 

Degeneration of the column of Burdach is common, as seen 
in Weigert-Pal preparations, not only in tabetic cases but also in 
many others which have not shown tabetic symptoms during 
life. The central canal of the cord is filled with nuclei in some 
places and distended in others. The anterior and posterior spinal 
roots usually show signs of primary degeneration. 

If a comprehensive view be taken of the lesions above described, 
it will be seen that the parts of the nervous system which suffer 
most are those which are most accessible to the cerebro-spinal 
fluid :—the dura mater and pia arachnoid; the cortex, especially 
the motor cortex, with its abundant supply of perivascular 
lymphatics; the tangential fibres; the cranial nerves and spinal 
nerve-roots; the walls of the ventricles, especially the floor of 
the fourth ventricle over which every drop of cerebro-spinal 
fluid must flow on its way from the choroid plexuses to the 
foramen of Magendie; the central canal of the cord; the pulvinar 
and the cortex of the cerebellum. The tract degenerations in 
the interior of the central nervous system are all secondary to 
these lesions. The conclusion appears to be irresistible that the 
specific toxin of general paralysis is to be found in the cerebro- 
spinal fluid and that it is already present when that fluid is 
secreted from the choroid plexuses. 

Now although this fluid has been the object of most careful 
chemical and histological examination, the toxin appears to 
have hitherto eluded observation; but we now know from 
Noguchi’s discovery that it is a spirochetogenic toxin. There 
- is excess of albumin and nucleo-proteid in the fluid; and cholin, 
one of the products of degeneration of nervous tissue, is to 
be found in the fluid. Cholin is a substance known to be 
capable of both lowering the blood-pressure and inducing fatty 
degeneration of tissues. It may therefore be held responsible 
for the extensive fatty degeneration found in patients who 
have died of general paralysis and also for the lowered blood- 
pressure, reported by Sir Maurice Craig, in the terminal 
stages of the disease. Dr. J. Turner found sugar to be deficient 
in lumbar puncture fluid of general paralysis and ascertained that 
it entirely disappeared post mortem. It occasionally happens 
that the fluid coagulates shortly after it has been collected, 
quite apart from any admixture of blood from subdural 
hemorrhage or otherwise. 

The pressure of the cerebro-spinal fluid is abnormally high. 


462, MIND AND ITS DISORDERS 


Schaeffer made fifty-three punctures in twenty-five cases and 
found an average pressure of 182 millimetres; in two-thirds of 
his cases the pressure was between 250 and 280 millimetres, 
whereas the normal pressure is certainly less than 150 milli- 
metres. 

For cell changes in the cerebro-spinal fluid see Fig. 72 and. 
Appendix B. The colloidal gold test for general paralysis is 
also described in Appendix B. | 

Psychopathology.—Hollos and Ferenczi have made a psycho- 
analytical study of the psychic disorder of general paralysis, not 
by subjecting general paralytics to psycho-analytical technique, 
but by giving their own interpretations of certain symptoms of 
the patients as in applied psycho-analysis. 

It is especially from a study of the delusions respecting age, 
time, duration, numbers and such like that Hollos concludes that 
these wish-fulfilments relate to the inception of the disease (either 
the syphilis or the first mental difficulties), as if the patient is 
seeking to escape from the truths of reality (the facts of his 
disease) from that date onward. In other words general paralysis 
is a patho-psychosis analogous to Ferenczi’s patho-neurosis. The 
delusions of strength and well-being are a reaction against the 
patient’s weakness and malaise, while the depression in the 
depressed cases is again found by interpretation to refer to the 
malady itself. 

In addition to all this the physical degeneration of the cerebral 
cortex weakens the repressing forces of the patient, and he 
therefore regresses to an infantile instinctual life, the colouring 
of the clinical picture varying, and the man is, for example, 
strongly narcissistic, oral-neurotic or sadistically anal-erotic. 


ay 
ial 
ENDOTHELIAL CELL 
ts, 
Sa \n\ 
fy c' SPINDLE CELL 
PLASMA CELL—/— ee Ve (Fisro BLast @) 


PHAGOCYTE 
GincLusion oF 
LYMPHOCYTE 


ENDOTHELIAL 
CELL 


MITOTIC CELL 
? PLASMA CELL 


LYMPHOCYTE —& ¥ PLASMA CELL 


ENDOTHELIAL CELL 


Pitre 


FILM MADE FROM THE CEREBRO-SPINAL FLUID OF A GENERAL PARALYTIC 


STAINED WITH PAPPENHEIM'S PYRONIN-METHYL-GAEEN 


Preparation and Drawing by Dr J. G. PHILLIPs 


To face page 462 


CHAPTER XVIII. 


MENTAL DISORDERS ASSOCIATED WITH COARSE 
CEREBRAL LESIONS. 


In this chapter we have to consider the characters and relation- 
ships of mental disorders arising in association with and appar- 
ently resulting from— 

1. Injury to the head. 

2. Embolism or thrombosis of one or more cerebral arteries, 
whereby some part of the brain is destroyed and dies for want of 
blood-supply. 

3. Cerebral hemorrhage, abscess or tumour destroying some 
local portion of the brain-tissue and causing an increase of the 
general intracranial pressure. 

4. General inflammatory conditions such as encephalitis and 
meningitis. 

In many cases of organic cerebral disease the mental disorder 
conforms to one of the types already described in this manual. 
In such circumstances the brain lesion is to be regarded merely 
as a contributory cause of the mental syndrome since the latter 
presents no characteristic symptoms of a coarse brain lesion. 
It is to be remarked that the presence of organic brain disease 
renders recovery improbable, even in cases of an apparently 
functional psychosis the prognosis of which is usually regarded 
as favourable. Such cases require no further notice in the present 
chapter, which is devoted to the consideration of the symptoms 
directly traceable to the brain lesions. 

These symptoms may be classified under three headings, ac- 
cording to their causation by— 

1. Increase of intracranial pressure. 

2. Cerebral intoxication by products of neural disintegration or 

3. Interference with some portion of the cortex which has a 
specialized function in mentation. 

Symptoms of Increased Intracranial Pressure.—These occur in 
cases of abscess or tumour of the brain, in meningitis and in 
encephalitis. 

463 


464 MIND AND ITS DISORDERS 


Headache is the most common symptom. As a rule this is — 
fairly persistent, but sometimes it is paroxysmal. It is usually 
worse in the early morning, when it is commonly associated with 
vomiting ; but the headache associated with gummata of the brain 
is frequently worse at night. 

Double optic neuritis occurs in about 80 per cent. of Athy cases 
of cerebral tumour and of tubercular meningitis; it is much less 
frequent in cases of simple cerebro-spinal meningitis. | 

Vomiting is another fairly constant phenomenon. It appears 
especially in association with exacerbations of the headache and 
not uncommonly it is replaced by a feeling of nausea. 

Generalized convulsions occur in a small number of cases. 

The pulse and respiration are less frequent than normal, the 
latter being affected more than the former. 

The mental symptoms comprise a general retardation of the 
mental faculties, with slowness of movement, slowness of speech 
(bradyphasia), slowness of perception, apathy and loss of memory. 
Puerility is also a somewhat characteristic symptom; the patients 
are childish in their tastes and like to follow childish pursuits, 
but they lack the activity and lively curiosity of the child. In 
the later stages drowsiness sets in and gradually deepens to 
stupor and coma. 

Some of the above symptoms have been described, at least in 
part and notably by the French school, to intoxication by the 
products of neural disintegration, but the view is little accepted 
in this country. 

Symptoms of Cerebral Poisoning by Products of Neural Dis- 
integration.—These are the symptoms already described under 
the heading of Acute Confusional Insanity, to which disease 
the reader is referred. Here they need only be summarized as 
follows: peripheral analgesia, imperception, disorientation in 
time and place, hallucinations (especially of vision and hearing), 
disturbance in the association of ideas leading to incoherence of 
speech, loss of memory, lack of volition with inability to con- 
centrate the attention, apraxia and degeneration of the instincts 
with mischievous and often dirty habits. 

Focal Symptoms.—The psychical symptoms associated with 
tumours of the frontal lobe are more liable to occur with sub- 
cortical than with cortical tumours. The symptoms are of two 
kinds, active and passive. 

Among the active symptoms are irascibility, irritability, petu- 
lance and quarrelsomeness. There is loss of control of the 
instincts and the patients sometimes fall into the hands of the 


ORGANIC BRAIN DISEASE 465 


police through degeneration of the moral sentiment. This occurs 
most commonly in association with tumours near the orbital 
surface of the frontal lobe. Joviality, inability to take the 
medical examination seriously, frivolity and a persistent tendency 
to jest are said by some authorities to be characteristic of frontal 
tumours. The symptom has received the names “ Witselsucht ”’ 
and “‘ Moria’’. Perhaps it arises most commonly in association 
with frontal tumours, but it may occur with tumours of other 
regions, and also in some cases of dementia of apparently func- 
tional origin. 

The passive symptoms of frontal tumour are obtuseness, 
hebetude and loss of memory. 

It is said that the passive symptoms occur more frequently 
with tumours of the left and active symptoms with tumours of 
the right frontal lobe. It may now be considered as settled that 
the physical basis of voluntary action is situated in the left 
frontal lobe and that apraxia or paralysis of volition indicates 
disorder (functional or organic) of the same region. Left-sided 
apraxia occurs in association with lesions of the right frontal lobe, 
and bilateral apraxia is also caused by lesions of the anterior part 
of the corpus callosum. 

From a neurological point of view tumours of the corpus 
callosum resemble those of the frontal lobes in that they give 
rise to none of the symptoms looked for by the pure neurologist. 
There is no disturbance of sensation or movement, or any charac- 
teristic alteration of the reflexes; tumours of this region cannot 
be diagnosed neurologically until they are large enough to 
involve neighbouring structures; the earliest symptoms are 
mental. It is not surprising that tumours of the corpus callosum 
are invariably associated with psychical symptoms when we 
consider that such tumours interfere, not only with the associa- 
tion fibres constituting the great commissure connecting the 
two cerebral hemispheres, but also with those of the superior 
longitudinal bundles. The patients are dull, obtuse and con: 
fused. They are disorientated in time and place and there is 
complete loss of memory for recent events. There is inter- 
ference with the association of ideas, leading to incoherence of 
speech. Voluntary action, including voluntary attention, is in 
abeyance. Judgment is deficient, and the patients are quite 
incapable of mental work of any kind or of sustained physical 
work. In other words the clinical picture is that of profound 
dementia. 

Tumours of the posterior half of the cortex of the left temporal 

3° 


466 MIND AND ITS DISORDERS 


lobe induce (in right-handed people) word-deafness; they cannot 
understand what is said to them (verbal auditory imperception). 
A lesion of both temporo-sphenoidal lobes produces complete 
auditory imperception so that the patient cannot, for example, 
recognize music or the ringing of bells as such; but this may 
also arise from extensive left-sided lesions. Subcortical and 
supracortical tumours in the neighbourhood of the auditory 
centre are liable to induce hallucinations of hearing. . 

Tumours behind the left angular gyrus give rise (in right-handed 
people) to loss of perception and ideation of written language 
(word-blindness). The patients are unable to comprehend the 
meaning of written or printed words or sentences. Usually they 
are unable to express their thoughts in writing. They can copy 
writing into writing and print into print, just as an average 
Englishman could copy Chinese without knowing the meaning; 
but they cannot copy print into writing or writing into print, 
because such a process involves an act of perception of the 
nature of the symbols which are being copied. This imper- 
ception is for written and printed language only; objects can 
usually be recognized and named at sight. It is probable that 
lesions of both angular gyri (right as well as left) produce com- 
plete visual imperception. Occasionally complete visual imper- 
ception is caused by very extensive lesions of the posterior half 
of the left hemisphere, involving the occipital and portions 
of the parietal and temporal lobes with the subjacent white 
matter. 

When a lesion of the left angular gyrus is sufficiently extensive 
to involve also the posterior part of the temporal lobe, the 
patient is unable to name objects at sight although he recognizes 
them and knows the uses to which they may be put. Delirium, 
stupor and states of mental confusion with hallucinations are 
especially liable to occur in association with tumours of this 
region. Lastly, subcortical and supracortical tumours in the 
neighbourhood of the angular gyrus tend to produce visual 
hallucinations. 

Lesions of the base of the brain are not especially apt to cause 
mental symptoms unless they are in the neighbourhood of the 
pituitary body. In the latter region tumours tend to produce 
loss of the sexual instinct, with depression and suicidal ideas. 
In a few cases there is maniacal excitement or delirium with 
hallucinations. 

Some idea of the frequency with which tumours in various 
regions of the brain are associated with mental symptoms may 


FOCAL SYMPTOMS 467 


be derived from the following table compiled by Schuster from 
the study of 588 cases, of which 323 showed mental symptoms: 


Per Cent. 
Tumours of the corpus callosum .. a eee LOO 
Tumours of the frontal lobe be Fae oe 79°3 
Tumours of the temporal lobe .. he RS 66:6 
Tumours of the pituitary region .. ot 2 65°3 
Tumours of the occipitallobe .. oe ae 60 
Multiple tumours ae is oe a 59°6 
Tumours of the pineal gland 4 ite se 53°8 
Tumours of the parietal lobe me a os 52°1 
Tumours of the basal ganglia... oe an 50 
Tumours of the cerebellum ae ne . 35°5 
Tumours of the centrum ovale... ee a 28°8 
Tumours of the cerebral peduncles S ae 25 


The mental enfeeblement which is met with in cases of cerebral 
softening from thrombosis of one or more of the cerebral arteries 
is an exaggerated form of that described under the heading of 
Chronic Cortical Atrophy (Arteriopathic Dementia). 

In acute cerebro-spinal meningitis and in acute encephalitis a 
certain amount of mental and motor excitement is liable to occur 
during the prodromal stages; but, as the disease becomes estab- 
lished, the patient is more liable to become depressed, this 
depression being the forerunner of the terminal coma. 

The mental symptoms accompanying tubercular meningitis 
are less uniform in character. Some patients are excited and 
violent, others are depressed, others again develop delusions 
of persecution. Many are delirious and experience numerous 
hallucinations, while yet others show progressive mental deteriora- 
tion resembling dementia. 

There is no form of mental disorder which may be regarded 
as characteristic of head injury, even with traumatism to the 
brain. The cases conform to types of insanity elsewhere 
described in this volume and the head injury must be regarded 
merely as an exciting cause in a predisposed individual. 

For the prognosis and treatment of the various organic diseases 
of the brain mentioned in this chapter the student must consult 
a work on neurology or general medicine. 


CLA Pi geo 


ENCEPHALITIS LETHARGICA, EPIDEMIC ENCEPHALITIS, 
LEE PY SLC ION Bae 


ALTHOUGH many of us can look back upon some case which, in 
the light of our present knowledge, we now regard as one of 
encephalitis lethargica, and although several physicians have 
brought forward a certain amount of evidence to show that, even 
in its epidemic form, this is no new disease, it has been at least 
so rare that it has not received sufficient recognition to acquire 
a name until it made its practical début in worldwide epidemic 
form towards the end of the Great European War. Apparently 
the first cases (described by von Economo) occurred in Vienna 
in 1916, while in this country the epidemic reached a climax in 
1921, when 1,470 cases were notified. Since that time the 
numbers have been for 1922, 454 cases; for 1923, I,123 cases; 
but the incidence of the disease continues to increase very 
seriously, for in the first quarter alone of 1924 there were 2,468 
cases notified. 

Etiology Dr. A. S. MacNalty of the Ministry of Health 
regards this as an entirely new disease. However that may be, 
it would seem that the conditions of war supplied some pre- 
disposing factor. The same may be said of poliomyelitis, polio- 
encephalitis and influenza which, on the one hand, are supposed 
by many authorities to be bacteriologically related to encephalitis 
and, on the other, occurred in an increased epidemic form almost 
contemporaneously with, but really slightly before, the en- 
cephalitis plague. It has therefore been called a “ trailer”’. Its 
greatest incidence is in the spring, especially during the month 
of February. It is not known what particular factor of warfare 
predisposes to the ailment, but Dr. Browning of Brooklyn has 
drawn attention to the fact that many of the patients have, for 
many months preceding their illness, been subjected to abnormal 
fatigue, and especially to insufficient sleep. 

Among the victims males preponderate to a slight extent, and 
the disease occurs at all ages from the day of birth to old age. 


Pregnant women are said to be exceptionally liable—also doctors. 
468 


ENCEPHALITIS LETHARGICA 469 


Otherwise professions and trades have no etiological significance. 
Jews have shown special predisposition in most countries, and 
in tropical areas there is an exceptionally high mortality among 
the coloured population. It is often found that the patients 
have been already exhausted by some other fever, such as in- 
fluenza, pneumonia or searlet fever. 

The essential cause of the disease is a filter-passing micro- 
organism which—until quite recently—had not been definitely 
isolated, but had been cultivated symbiotically with cellular 
elements. These are generally obtained from the mouth, for 
which the virus has a peculiar affinity, for it can be found there 
in healthy carriers. Invasion is supposed to occur vid@ the nasal 
mucous membrane. Miss Alice C. Evans of the United States 
Hygienic Laboratory claims to have obtained a streptococcus 
from the brain of a patient who had died from the disease and 
to have passed it through seventeen successive rabbits, all of 
whom contracted the disease, quantities of the same micro- 
organism being found in the brain of each after death. It appears 
that these streptococci vary greatly in size, so that, while most 
of them pass through a Berkefeld filter, some grow large enough 
to be arrested. Small doses appeared to give a partial immunity 
to the animals. 

Symptoms.—Encephalitis lethargica varies in severity from 
an almost unnoticeable “cold in the head”’ to a malady of the 
greatest severity with a wealth of symptoms and physical signs 
of an organic affection of the nervous system, perhaps with 
hyperpyrexia terminating fatally in a week—or even in a few 
hours in status epilepticus. As if this were not bad enough, it 
tends to recur in some patients or to leave in its trail a number 
of sequel or residua of varying severity, not corresponding with 
the severity of the original illness. 

In most cases. there is initial headache, usually occipital, 
followed by a moderate rise in temperature and a thickly-coated 
tongue. The fever lasts until the end of the illness, which may 
be weeks, months or even, in one case (Lhermittés), two years 
afterwards. Usually it lasts about three weeks. 

The characteristic symptom responsible for the names given 
to this disease is lethargy or sleep. This is nearly always present, 
so that the patients have to be awakened for meals or even fall 
asleep during meals. In some cases the sleep is deep enough to 
be called coma, and the patient has to be tube-fed. 

The brunt of the illness is borne by the cerebrum and mid- 
brain. Thus there are usually signs of oculomotor paralysis, 


470 MIND AND ITS DISORDERS 


such as divergent strabismus with diplopia, ptosis (unilateral or 
bilateral), nystagmus and loss of the pupillary reflex. Much more 
rarely, other cranial nerves are more or less affected, especially 
the fifth, sixth, seventh and twelfth. 

The muscles are generally hypotonic with loss of the tendon | 
reflexes, but sometimes the limbs are spastic with increased knee-_ 
jerks. In yet other cases there is a typical flexibilitas cerea 
(catalepsy). A curious phenomenon not uncommonly seen is 
twitching of muscular fasciculi; sometimes it is so slight that it 
has to be looked for, in other cases it may be strong enough to 
move the limb. 

Hemiplegia may occur with or without aphasia, also with or 
without hemianesthesia. More rarely there is paraplegia or a 
monoplegia, and difficulty of articulation is not uncommon. 

Apart from such cases sensation appears to be normal in 
milder forms of the disease, but some peripheral analgesia is 
usually associated with profound lethargy in normal sleep. 

The superficial reflexes may be unaffected, but quite frequently 
the abdominal reflexes cannot be elicited, and the Babinski feet 
or toe sign may be present. The tendon reflexes are rarely 
quite normal; the knee-jerks may be either exaggerated or, more 
rarely, absent. 

Of the organic reflexes many are liable to disturbance, such as 
difficulty of swallowing, attacks of dyspnoea, hiccough and reten- 
tion of urine. The last should always be looked for, and the 
physician must not be deceived by an overflowing full bladder. 
Salivation may be excessive, and profuse sweating is often a 
striking symptom. 

The other systems are rarely affected, but the following lesions 
and symptoms have been noted:—inflammation of the salivary 
glands, epidemic hiccough, obstinate constipation (very rarely 
diarrhcea), hamatemesis and melzna, polyuria, herpes febrilis 
and herpes zoster. 

Sequele.—The name of these is legion. In some cases these 
follow immediately after the acute illness, but more frequently 
there is an interval which may be as long as six months. 

Taking them more or less in order of frequency, the commonest 
is the Parkinsonian syndrome, which is indistinguishable from 
paralysis agitans except that it appears earlier in life. I have 
seen it as early as seven years of age. If there is any difference, 
I would be inclined to say that the tremor tends to be less than 
in paralysis agitans, but the general disability much greater, 
having regard to the duration of the malady. It may also be 


SEQUEL& OF ENCEPHALITIS LETHARGICA 471 
complicated by one or more of the other sequel, the commonest, 
perhaps, being excessive salivation (sialorrhcea). 

Involuntary movements of various kinds may occur. Perhaps 
the most characteristic of these are rhythmical jerkings of one 
or both shoulders or hips. In one of my cases (shoulder), these 
were synchronous with the heart beat. 

Sometimes the movements are myoclonic in character or, 
quite as commonly, athetoid or choreiform. In some cases they 
are quite violent and even painful. Cataleptic flexibilitas cerea 
(often erroneously called katatonia in the textbooks) may appear 
as a late manifestation. Torticollis has also been recorded. 
Partial paralysis, similar to those occurring during the acute 
illness, are sometimes seen. When hemiplegic in distribution, 
the hemiplegia tends to be of the crossed type, as in lesions of the 
brain stem. The optic thalamus cases are characterized by 
weakness of one side of the face for volitional movement and of 
the other side for an involuntary smile. 

Other physical residua are abnormal obesity, atrophy of the 
genitalia, hyperidrosis and ichthyosis, hurried respiration alter- 
nating with apnoea and tics of respiration. 

Mental Sequele.—These are very rarely of such a nature as to 
necessitate certification. When they do, in my experience they 
are invariably of a confused type, with or without excitement, 
depression or stupor. It is, however, extremely common for 
chronic nervous exhaustion (acquired neurasthenia) to supervene, 
the patients being incapable of sustained effort of any kind, and 
therefore unemployable. Bad temper is sometimes reported in 
these cases, but this is probably but a normal reaction to being 
bullied by their relatives for laziness, which they have not recog- 
nized to be pathological. 

In children the most striking and characteristic changes occur 
in the moral sphere. They become disobedient and uncon- 
trollable, and take to stealing, lying and savagery. They make 
brutal attacks with weapons on their brothers, sisters or pet 
animals of the house. These cases are now becoming so frequent 
that the Metropolitan Asylums Board is setting up special institu- 
tions to deal with them. 

. Morbid Anatomy.—tThe only characteristic lesions are found in 
the central nervous system, and are most marked in the mid- 
brain and pons. The meninges are cedematous, and in some 
cases thickened. The centrum ovale is unduly wet, the puncta 
cruenta are well marked, and the ventricles may be dilated. 
Microscopically the smallest bloodvessels show a perivascular 


472 MIND AND ITS DISORDERS 


‘ cuff” of infiltration by cells with round, deeply stained nuclei. 
There are also small scattered masses of plasma cells, lympho- 
cytes, and perhaps polynuclear cells in the nervous parenchyma. 
There are also the usual signs of neuronal degeneration. In the 
cerebral cortex the “elective zone’’ (as authorities style it) is 
the hippocampus. ) 

Prognosis.—The mortality varies between 20 and 50 per cent., 
death occurring at any time during the first month, but usually 
in the third week of the disease. Among those who survive the 
acute illness, at least two-thirds have some sequel or residua 
from which they never completely recover. 

Treatment.—During the acute stage the patient should, of 
course, be nursed in bed. The diet should not be stinted, but 
it should usually be of a light, liquid and nutritious nature. 
Half a bottle of champagne in the course of the day or an equiva- 
lent amount of dilute brandy is to be recommended. When the 
stupor is profound or swallowing difficult all nourishment and 
medicines must be given through a stomach-tube. 

The only specific treatment is to disinfect the mouth, throat 
and cerebro-spinal system. The former is achieved by frequent 
washing, gargling or swabbing of the mouth and throat with a 
solution of potassium permanganate (I in 100), and the latter by 
internal administration of— 


Hexamine, . bs ee is tte gies, 
Acid sodium phosphate .. +7 se + Pl eve 
Water are a5 ie a is oo he 


Every six hours. 


As there is every probability that the infection still persists during 
the sequelz, these should be treated in the same way. 

The physician should be on the look-out for retention of urine 
during the acute stage, and a catheter passed if necessary. 

For the Parkinsonian rigidity, the best drugs are tincture of 
hyoscyamus (or hyoscine hydrobromide) in full doses and injec- 
tions of cacodylate of soda, 5 grains on alternate days for about a 
month at a time. Dr. Hall of Sheffield recommends full doses 
(say 20 minims) of tincture of belladonna three times a day for 
this condition, and also for the sialorrhcea which so frequently. 
accompanies it. The effective alkaloid in both hyoscyamus and 
belladonna is said to be levo-hyoscyamine. 


CrlAtLE KS XX. 
CHRONIC CORTICAL ATROPHY 


(ARTERIOPATHIC AND SENILE DEMENTIAS.) 


In this group are comprised a number of cases presenting similar 
clinical features and characterized anatomically by cortical 
atrophy. In one class this cortical atrophy is due to wasting 
of the parenchymatous elements as the result of senility, prema- 
ture or otherwise; these have lived their day and they disappear 
by a process of abiotrophy. In another class the disappearance 
of the cortical elements is due to malnutrition of the cortex from 
degeneration of the cerebral arteries, these having become 
sclerosed as a result of alcoholism or plumbism, as a sequel to 
some specific fever or in association with cirrhosis of the kidney 
(arteriosclerotic insanity). This form of dementia is usually 
encountered among persons who have attained at least their 
fifty-fifth year; but it is occasionally met with as early as the 
fourth decade in consequence of past syphilis causing cerebral 
endarteritis or atheroma (syphilitic dementia). I have also met 
with a case of this nature resulting from chronic sulphonal 
poisoning for sixteen years, the patient being only fifty years 
of age at the time of the consultation. 

Physical Signs.—Apart from hemiplegia, due to cerebral 
thrombosis and softening, which is liable to arise in most of 
the above conditions, the physical signs associated with arterio- 
pathic dementia are those of the disease which has given rise to 
the arteriopathy. In old age, for example, there is loss of flesh, 
especially in the limbs and face, the face becoming wrinkled 
and the eyes sunken. There is fatty degeneration of the upper 
and lower margins of the cornea (arcus senilis), dimness of vision 
due to slight opacity of the ocular media, weakness of accom- 
modation, myosis and diminution of the pupillary reaction to 
light. Fibrosis of the tympanic membrane is responsible for 
some difficulty of hearing in general and perhaps for the failure, 
which I have noted in many cases, to hear the high-pitched 
notes of a Galton’s whistle. There is general muscular weakness, 

473 


474 MIND AND ITS DISORDERS 


often accompanied by tremor on movement. The old man is 
unable to stand upright and this, as well as a certain amount 
of flattening of the intervertebral discs, leads to diminution of 
stature. The superficial and deep reflexes are usually diminished. 
Urine is passed with excessive frequency, the urinary passage 
being obstructed by an enlarged prostate and the bladder thereby 
distended. Prostatic enlargement occurs in about 34 per cent. — 
of men over sixty years of age. In all cases of general arterio- 
sclerosis, both young and old, the urine is abnormally abundant 
and dilute. 

In the syphilitic cases, there is usually some physical sign of 
the patient having previously contracted that disease, such as 
psoriasis palmaris, pigmentation of the skin of the leg in the site 
of a former ulcer, scarring of the fauces from previous ulceration, 
enlargement of the glands behind the sterno-mastoid, or ocular 
palsy of some kind. Some of the patients suffer from tabes and 
are liable to be mistaken for general paralytics; the differential 
diagnosis is sometimes rendered exceptionally difficult by the 
occurrence of epileptiform and apoplectiform attacks. The 
pressure of the cerebro-spinal fluid is often raised and there may 
even be a mild leucocytosis with presence of globulin. 

Mental Symptoms.—Although, owing to the multitude of 
causes of chronic cortical atrophy, the physical signs met with 
in these patients may be diverse, there is great uniformity in the 
mental symptoms. 

The earliest stages are characterized by headache, attacks of 
giddiness, somnolence during the day and insomnia at night. 
The patient is slow in thought and movement, and emotional 
reaction is excessive so that he becomes irritable or perhaps 
unduly sentimental. A paranoid condition sometimes develops 
with delusions of neglect and persecution and often with hypo- 
chondriacal delusions. Apart from the dimness of vision and 
difficulty of hearing due to local causes above mentioned, there 
appears to be no diminution of sensation in any department, 
even in most advanced cases. 

As the disease progresses 1mperception occurs and is demon- 
strated by the patient’s failure to distinguish between blues and 
greens and by his inability to take in the meaning of simple 
sentences or of pictures. 

Later he becomes unable to recognize objects or at least to 
give them a name. He is disorientated in time and place, does 
not know where-he is, has no idea of his age and is unable to 
say what year itis. In typical cases hallucinations do not occur. 


CHRONIC CORTICAL ATROPHY 475 


There is poverty of tdeation and lack of coherence in the train 
of thought, any chance percept being sufficient to divert the 
patient’s purely instinctive attention; voluntary attention is 
practically obliterated. 

Failure of memory is noticeable from the first. Difficulty of 
remembering proper names marks the beginning of the amnesia, 
which is slowly progressive, the memory subsequently under- 
going dissolution according to the laws laid down on pages I41-2. 
The cortical perception centres are incapable of retaining new 
impressions and the patient lives in the past. He forgets where 
he places things and perhaps accuses others of having stolen 
them. 

Motor and agnostic apraxia occur in this disease more con- 
stantly than in any other form of mental disorder. In the 
early stages the patient makes mistakes in his ordinary work, 
later he loses the faculty of using objects correctly. Ideational 
inertia is common; for example, if the patient be shown a foun- 
tain-pen, he will take off the cap (action correct); if next he 
be shown an ordinary pencil, he may try to do the same thing 
with it (action incorrect owing to inertia of ideation). This 
phenomenon is sometimes to be observed in letters written by 
these patients, the same phrase or sentence recurring from 
beginning to end (vide letter on pages 161 and 162). 

Flexibilitas cerea may sometimes be noted. 

With imperception agnostic apraxia occurs as a matter of 
course; the patient is unable to use an object correctly because 
he does not recognize its true nature. 

The conduct is characterized by restlessness without energy 
and undue tendency to fatigue. There is progressive loss of 
control of the emotions and instincts. These patients may 
laugh, weep or show irritability on very slight provocation. 

In a previous chapter it has been remarked that loss of control 
of the instincts occurs in the reverse order to that in which 
control of them is attained in early life, roughly in the reverse 
order of their evolution. In senile dementia control of the 
sexual instinct is lost disproportionately early, partly on account 
of some local irritation caused by prostatic enlargement. This 
is of considerable medico-legal importance on account of the 
frequency with which old men, hitherto unsuspected of mental 
disorder and bearing a spotless reputation, are suddenly arraigned 
before a criminal court for a sexual offence, often of a perverse 
character. There is a stage in the decay of the old man during 
which the instinct of possession shows itself in an exaggerated 


476 MIND AND ITS DISORDERS 


form. He perhaps marries a girl of twenty to gratify his sense 
of power; and as regards his worldly possessions, he becomes 
abnormally canny and suspicious lest others should attempt to 
deprive him of them, but lacks the enterprise necessary to 
increase them. Similar loss of control, paralysis of volition, — 
occurs in the arteriopathic cases. Dissolution steadily pro- 
gresses; the patient may take to collecting rubbish and, in his 
second childhood, return to the age of make-believe and play. 
Finally, the instincts themselves disappear, the patient becoming 
wet, dirty and bedridden like a general paralytic. 

The judgment is defective, but there is no great tendency to 
the formation of delusions. Any delusions which arise are 
directly dependent on the loss of memory. 


rege Deoriat 
WNAe yo pena The shi bpene ‘ 


Pend me abo Srwe cough dnohe 
- any Kerk tf stele you Mary be ahie 
la gue Thar Lye VieZ  - 


FIG. 73.—SENILE WRITING. 


The infantile desire for sweets is worth noting. 


Throughout the whole course of the disorder insomnia at 
night is the rule and is accompanied by motor restlessness. In 
the daytime, however, these patients are peculiarly liable to drop 
off to sleep in the midst of a conversation and even when actually 
speaking. 

There is no disturbance of articulation, but the content of 
thought is so disjointed that speech may be incoherent and 
senseless. Perseveration is common, the patient repeating the 
same remark over and over again. , 

Diagnosis.—The disease which most closely resembles chronic 
‘ cortical atrophy is general paralysis; not that the latter is so 
liable to be mistaken for the former as the former for the latter. 
Difficulty of diagnosis is most likely to arise among syphilitic 
cases, especially among those presenting symptoms of tabes. 


DIAGNOSIS OF SENILITY Ag. 


Mistakes are to be avoided by attention to detail. Tertiary 
manifestations are rare in general paralysis, but common in 
syphilitic dementia; in general paralysis, attacks of paralysis 
are transitory, in chronic cortical atrophy they are permanent; 
in chronic cortical atrophy, the dysarthria characteristic of 
general paralysis is wanting. The writing shows evidence of 
hand tremor in both classes of patients; but the senile dement 
does not omit and repeat words and letters as the general para- 
lytic does. Moreover, senile tremor does not affect the tongue. 
The knee-jerk is increased in general paralysis in a characteristic 
manner, except in the tabetic cases; whereas it is diminished 
in chronic cortical atrophy. Lastly the disturbances of per- 
ception, orientation, memory and conduct are much more pro- 
found, relatively to the physical condition of the patient, in 
chronic cortical atrophy than in general paralysis. Delusions, 
on the other hand, are more common in general paralysis. 

Acute confusional insanity, which may closely simulate chronic 
cortical atrophy, is to be differentiated by the presence of hal- 
lucinations and peripheral anesthesia. 

In some patients who are subject to attacks of melancholia, 
chronic cortical atrophy is liable during its early stages to simu- 
late that disease. In such cases special attention should be 
directed to the state of the memory. 

No sharp line can be drawn between ordinary senile dotage 
and senile dementia. The normal mental deterioration incident 
upon old age is itself early senile dementia. The medical man 
is likely to be asked in a court of law at what stage of senile 
decay a man is to be regarded as insane; but the question cannot 
be answered and it is best to allow each case to be considered 
on its own merits. 

Prognosis.—This form of dementia is indicative of an extensive 
and progressive organic degeneration of the nervous system; 
there is consequently little hope of amelioration of the patient’s 
condition by treatment. 

In the syphilitic cases the disease may be arrested, but not 
cured, by the administration of mercury and potassium iodide; 
in the others death may be expected in five to ten years. Potas- 
sium iodide appears to be beneficial also in the non-syphilitic 
cases. I use it therefore as a routine medicine for all patients 
suffering from chronic cortical atrophy. In some of the senile 
cases dissolution takes place within a few months. 

Pathology.—The most striking feature at an autopsy on one 
of these patients is the great wasting of the brain. 


478 MIND AND ITS DISORDERS 


The dura mater is firmly adherent to the skull-cap and patchy 
meningitis interna hemorrhagica is sometimes found. The pia 
arachnoid is thickened and cedematous and there is an increase 
of Pacchionian bodies. The membranes may be stripped from 
the cortex with unusual facility. 

The cortex is thinner than natural and the convolutions are 
atrophied. The whole of the brain is wasted and not uncom- 


I'IG. 74.—SENILE BRAIN FROM A PATIENT FORMERLY OF EXCEPTION- 
ALLY HIGH INTELLECT. 


Under observation he showed marked apraxia and agnosia. Note the 
atrophy of the frontal lobes. (The asymmetry is only apparent, 


being due to post-mortem change while the brain was lying in 
formalin.) 


monly weighs less than 40 ounces; but the atrophy is most 
marked in the frontal lobes, especially in their lateral aspect. 
As a result of this atrophy there is great excess of cerebro-spinal 
fluid, the ventricles are dilated and the pia arachnoid, which 
is usually thickened and studded with large Pacchionian bodies, 
is cedematous. The pia arachnoid may be readily stripped 
from the convolutions without tearing them. 


PRESBYOPHRENIA 479 


In abiotrophic cases the wasting of the brain is due to primary 
atrophy of the neuronal elements of the cortex; in the arterio- 
pathic cases the neuronal degeneration is due to malnutrition 
caused by thickening of the cerebral arteries. 

There may be extensive degeneration of the bloodvessels 
throughout the body, but the cerebral arteries suffer most. The 
thickening is of the inner coat in the syphilitic, of the middle 
coat in the arteriosclerotic cases. Miliary aneurysms may 
often be detected by manipulating portions of the brain in a 
stream of running water and subsequent microscopical ex- 
amination. Following on the arterial degeneration there are 
frequently small foci of softening in the Rolandic areas of the 
cerebrum and around the smaller vessels of the basal ganglia, 
especially of the lenticular nucleus. These frequently present 
on section a spongy aspect from dilatation of the periarterial 
spaces (état criblé). This is probably the cause of the tremor. 
Fischer describes certain “ gland-like ’’ enlargements on the nerve 
fibres in such necrotic foci, which he regards as peculiar to this 
disease. Microscopic examination of the cortex reveals ex- 
tensive, at first pigmentary, degeneration of the nerve-cells, 
best seen in the motor area, with consequent degeneration of 
motor fibres of the corona radiata. Accompanying these changes 
there is extensive proliferation of neuroglia, especially in those 
parts where the felt-work is normally dense; for example, just 
beneath the ependyma. Alzheimer describes a_ perivascular 
gliosis with destruction of nervous tissues round the vessels. The 
cortex is infiltrated with spider-cells (scavenger-cells of Bevan- 
Lewis). Macroscopically this sometimes gives rise to a slightly 
frosted appearance of the floor of the fourth ventricle. Small 
cysts may be found in the choroid plexuses. 

Microscopic examination of the medulla and spinal cord reveals 
similar changes, degeneration of motor cells and fibres. There 
is even some degeneration of the myelin sheaths of the peripheral 
nerves. 

The kidneys being usually cirrhotic, the renal cortex is thinner 
than natural and may contain a few cysts. 


PRESBYOPHRENIA. 


This is rather a rare mental disorder occurring in the senile 
or presenile period and usually regarded as an involution; but 
the symptoms and signs are so suggestive of some form of chronic 
intoxication that it is doubtful whether presbyophrenia is not 


480 MIND AND ITS DISORDERS 


incorrectly named and to be described as an independent disease. 
The reader will notice its remarkable resemblance to poly- 
neuritic insanity. 

Etiology.—As a rule no cause of presbyophrenia can be dis- 
covered; but a few cases date their origin from some acute illness, ~ 
such as influenza, bronchitis, gastro-intestinal catarrh or a head 
injury. I have not seen the disease in any patient under fifty-— 
five years of age. 3 

Symptoms.—Sensation is usually unaffected, but in some 
patients one side of the body is less sensitive than the other. 

Perception is profoundly disturbed. The patients mistake 
identities and are completely disorientated in both place and 
time. They do not know where they are and, even after they 
have been in an asylum for some months, quite readily accept 
the suggestion that it is a church, a theatre or their own home. 
They have no idea of the date and, if they attempt to guess 
what year it is, may be more than fifty years out. Often they 
cannot tell whether it is morning or evening, winter or summer. 
Yet these patients are mentally accessible and can follow an 
ordinary conversation fairly well. 

Similarly there is gross disturbance of memory. They forget 
almost immediately what they have only just heard, seen or 
done unless it has excited considerable emotion. Often they 
cannot make even an approximate guess at their own age, 
remember the death of their parents, know how many children 
they have or tell their names. Yet they can remember some 
things of importance in their everyday life, such as the price of 
food, how to prepare certain dishes, and such like. 

There are illusions of recognition and memory. The patients 
greet strangers as old friends and recognize places as familiar 
where they have never been before. Similarly there is a tendency 
to confabulation ; they relate incidents which have not happened 
and believe them to be true (paramnesia)—that they have just 
come from a banquet, received a visit from their parents, attended 
a wedding yesterday etc. 

Presbyophreniacs are usually amenable to suggestion and 
persuasion, again like patients suffering from polyneuritic 
insanity. 

They have fairly good insight as a rule and sometimes show 
distress about their disorder of mind. Indeed, they will often 
make absurd excuses for their loss of memory or apparent 
ignorance. Such patients usually have no delusions; but a 
few complain of persecutions of various kinds, such as being 


ALZHEIMER’S DISEASE 481 


robbed, poisoned or altered by some mysterious means. Hallu- 
cinations practically never occur. 

These patients are liable to drop off to sleep at all times of 
day; but at night they are restless and often busy packing up 
their bedding in a corner of the room. Their conduct during 
the day, on the other hand, is fairly normal. 

Physical Signs.—A few presbyophreniacs show some signs of 
peripheral neuritis, such as pains along the nerve trunks, wasting 
of muscles and loss of the tendon reflexes; but such cases are rare. 

Headache is a common complaint. The pupils are small, 
sometimes unequal, and they react but feebly to light. 

There is general motor weakness with a shuffling gait and 
tremor of the senile type is usually present. Sometimes the 
weakness is more marked on one side than on the other. 

Morbid Anatomy.—The brain is wasted and microscopically 
shows the usual senile changes; but there is also extensive fatty 
degeneration of the cortical nerve and glia cells. The nerve- 
cells are ultimately destroyed without much disturbance of the 
kinetoplasm, so that their fibrillation is often more easily ob- 
served than in a normal specimen. Marinesco and others 
describe sclerotic “‘ plaques ’’ or nodules in various parts of the 
cortex. Some authorities regard them as normal in brains of 
persons over fifty years of age, but much more abundant in 
senile dementia. The nodules measure 15 w to 804 in diameter 
and each consists of a central nucleus which is readily stained, 
an intermediate zone of radiating filaments and an outer layer of 
doubtful nature. 


ALZHEIMER’S DISEASE. 


Although this rather uncommon malady has also been regarded 
as a morbid variety of involution it is probable that it will 
ultimately have to be given the status of an independent disease, 
not only because of the severity and large number of physical 
signs of nervous disease, but also because cases have been recorded 
as occurring as early as thirty-one, thirty-three and forty years 
of age. 

Symptoms.—During the first year or so of the disease there 
is gradual mental deterioration with poverty of ideation and 
general weak-mindedness. Ultimately, perception is lost even 
to a more profound degree than in presbyophrenia, so that the 
patients are unable to comprehend what is going on around 
them; much less can they take in the meaning of a picture, 


however simply and clearly it tells its story. There is complete 
31 


482 MIND AND ITS DISORDERS 


disorientation, to such an extent that the patients can only 
make feeble and futile attempts to find their way even on 
familiar ground. Auditory and visual hallucinations are fairly 
common. | 

There is also profound amnesia, not only for ordinary events © 
of both recent and remote date, but also for occupations to 
which the patients have been accustomed for many years. 
They appear to live in a world of their own, chatter, mutter, 
laugh and sing to themselves. They are dirty in their habits 
and perform all sorts of apparently meaningless actions, such 
as running aimlessly about, polishing the walls or floor of their 
room with spittle, picking at the bedclothes and so forth. 

Apraxia is an early symptom, but the most striking disorder 
is that of speech. At first the sentences hang together fairly 
well, but there is a tendency to repeat individual syllables and 
words several times before getting on with the sentence, some- 
what like stammering. Ultimately the speech is nothing more 
than a repetition of apparently meaningless syllables. Doubt- 
less the patient is trying to say something, but he is incapable 
of appreciating the complete failure of his efforts. 

Emotionally these patients are dull and apathetic. 

Physical Signs.—These are all motor. Epileptic convulsions 
are common, general tremor is fairly constant and twitching of 
individual muscles occurs. 

A form of bulbar paralysis occurs with characteristic difficulty 
of articulation and swallowing, with flabby paralysis of the 
tongue. There is also an amyotrophic spastic paralysis of the 
limbs and trunk with exaggeration of the tendon reflexes. 

Finally the patient becomes bedridden somewhat like a 
general paralytic and dies either from marasmus or some inter- 
current disease. 

Morbid Anatomy.—The brain is atrophied and presents the 
general appearances described on pp. 478-9. It was in these 
cases that Alzheimer first discovered the plaques mentioned 
on p. 481, but it has since then been found that they are almost 
a normal feature of senile brains. There is fatty degeneration 
of the nerve-cells as in presbyophrenia; but the appearance of 
the intracellular neurofibrils is rather different. They are 
thickened, fused together and formed into loops or whorls. 
Spider-cells are present in large numbers, as in general paralysis. 

Treatment.—In organic diseases of this nature the treatment 
can but consist of careful and kindly nursing with attention 
to the patient’s physical requirements and the administration of 


TREATMENT OF SENILE CASES 483 


mercury and potassium iodide in syphilitic cases. Potassium 
iodide is very often beneficial in arteriosclerosis also. Alcohol 
and tobacco should be avoided. The latter appears to be 
especially harmful to some of these patients, producing great 
confusion for an hour or so after smoking. 

The most important question which arises in cases of senile 
dementia is whether asylum treatment is necessary or not. To 
the author it appears desirable that considerable effort should 
be made to retain the patient in his own home, for it is surely 
a sad and serious thing that an old man should end his days, 
separated from home ties, in an institution for the insane. Of 
course every case must be considered on its own merits; un- 
fortunately the difficulty of nursing these patients at home is 
often insuperable and they are after all better off in an asylum. 
Any special tendencies to sexual aggressions or to suicide usually 
necessitate asylum sequestration and care. 


CHAE A oe 


MENTAL DISORDER ASSOCIATED WITH CERTAIN OTHER. 
NERVOUS MALADIES. 


CHOREA. 


THE characteristic feature of chorea is the occurrence of in- 
voluntary, irregular, sudden and somewhat jerky movements, 
muscular weakness and inco-ordination of voluntary movement. 
A detailed account of so common a disease would be out of place 
in a work of this nature; we therefore proceed at once to the 
consideration of the 

Mental Symptoms.—Most observers are agreed that cutaneous 
sensation is unaffected in uncomplicated chorea. Similarly 
hearing, vision, taste and smell are normal. 

The only disorder of perception is the somewhat rare occur- 
rence of hallucinations, usually of vision, rarely of other sense- 
modalities. 

Difficulties of ideation (the revival of memory-images) is one 
of the most striking symptoms. If, for example, a choreic 
patient be asked to name all the animals he knows of, he fre- 
quently cannot mention more than three and I have known 
one unable to remember any other animal thanahorse. Another, 
a girl of twelve, whom I asked to enumerate all the birds she 
could remember, could get no farther than a robin, cock-robin and 
robin redbreast. On the other hand, associative memory is fairly 
good for remote events, but it may be defective for recent events. 
Association of ideas is apt to be of the scatter-brained variety. 

All these disorders of ideation are due to lack of attention. 
The spontaneous involuntary movements and defective co- 
ordination render the attitude of attention impossible; the 
organism cannot be favourably adjusted for the reception or 
revival of sensory impressions. For the same reason the child 
is unable to learn lessons. 

The emotional tone is variable, being mostly determined by 
the attitude into which the patient is thrown by the choreic 
movements; he is by turns angry, fearful, fretful, capricious 
and irritable. 

434 


HUNTINGTON'S CHOREA 485 


Movement being entirely uncontrolled and dominated only 
by the caprice of the disease, volition is defective in severe 
cases. 

Various forms of insanity may arise episodically during the 
course of chorea. In such cases the choreic movements rapidly 
cease and become replaced by those characteristic of the par- 
ticular form of mental disorder which is present. In view of 
the frequency of chorea, the rarity of its occurrence as an ante- 
cedent of certifiable mental disorder and the variable nature 
of the insanity which occurs as a sequel to chorea, no direct 
relationship can be acknowledged to exist between chorea and 
insanity. Excluding cases of Korssakow’s disease induced by 
arsenical treatment, the author has seen cases of mania, melan- 
cholia, exhaustion psychosis and dementia przecox (katatoniac 
stupor) following directly on acute chorea, four cases out of 
some thousands. 


HUNTINGTON’S CHOREA. 


This rare disease, which has no relationship to the form above 
described, is a chronic incurable chorea which begins usually 
between thirty and forty years of age and is apt to occur in 
several members of the same family. It appears to be much 
more frequent in the United States of America than elsewhere. 

The movements are slower than those of Sydenham’s chorea. 
They affect the face, causing grimaces; the tongue, causing 
difficulty of articulation; the hands, interfering with the patient’s 
writing; and the lower limbs, causing an occasional drunken- 
looking lurch in his gait. In attempting to do things the 
muscular activity commonly overshoots the mark. 

Mental Symptoms invariably occur in association with this 
disease. At first the patients are irritable; later, depression of 
the melancholiac type dominates the clinical picture. As the 
disease progresses the capability of reviving memory-images is 
lost, as in Sydenham’s chorea; associative memory then becomes 
impaired and ultimately lost. Dr. Farquhar Buzzard’s patient 
whom I had the advantage of examining at a clinical meeting of 
the Neurological Society had well-marked imperception. He 
was unable to name at sight fairly common objects and he could 
not apprehend the meaning of other than simple sentences 
(agnosia). Agnostic apraxia, of course, was present and I 
thought that there was, in addition, some motor apraxia. 

All the intellectual faculties undergo progressive deterioration 
and the patient, after twenty or thirty years, becomes reduced 


486 MIND AND ITS DISORDERS 


to a condition resembling the terminal stage of general paralysis. 
Some authors, including Kraepelin and Binzwanger, have even 
gone so far as to regard Huntington’s chorea as a form of general 
paralysis. This view receives some degree of support from the 
post-mortem appearance of the brain, chronic leptomeningitis 
being present with adhesion of the pia mater to the cortex; but 
the absence of spider cells and plasma cells as well as the heredi- 
tary nature and invariably chronic course of the disease indicate 
an essential difference between the two disorders. 

Jelliffe and White, in their “‘ Diseases of the Nervous System ”’, 
say that “ the disease behaves as a complex in which age, motor 
disturbances and mental defect behave more or less independently 
of one another. When all three factors combine, the result is 
Huntington’s chorea ”’ 


PARALYSIS AGITANS., 


This disease is of particular interest to the psychiatrist on 
account of its resemblance to melancholia. In both there is a 
general attitude of flexion, in both there is proximal rigidity 
and in both there is a tendency to overaction of the muscles 
controlling movements at the small joints. 

In the chapter on melancholia the author has shown how 
misery is the result of this attitude. Similarly in paralysis 
agitans this attitude of misery induces a feeling of depression, 
at least in the later stages of the disease when the physical signs 
are well marked. There is often a vague sense of impending 
harm, sometimes amounting to suspicion. I have known a 
hospital patient become greatly agitated whenever there was a 
change of house physicians, knowing full well that some new 
drug would be tried on him, and fearing the worst. 

Like many melancholiacs these patients always feel warm and 
do not like to be near the fire. There is no Joss of sensation. 

Perception is liable to be impaired in long-standing cases 
and hallucinations of hearing sometimes occur. There is re- 
tardation of the train of thought and recent memory is some- 
times impaired in the later stages of the disease. The patients 
occasionally threaten suicide, but I have never heard of this 
threat being carried out. 

Diagnosis.—It will be remembered that a similar symptom- 
complex commonly occurs after encephalitis lethargica, and it is 
customary to diagnose this disease as having occurred whenever 
we meet with a condition resembling paralysis agitans in a person 


PARALYSIS AGITANS 487 


under fifty years of age. When we find it in a patient engaged 
in such trades as paint-, varnish-, enamel- or linoleum-making it 
may be due to chronic manganese poisoning. 

Jelgersma has described degeneration of the lenticular bundle 
of Forel and of the striothalamic fibres in two cases of paralysis 
agitans, and Hunt (Brain, 1917) ascribes the disease to degenera- 
tion of the motor cells in the globus pallidus. A lesion in this 
region has previously been suspected by neurologists on account 
of the coarse involuntary character of the tremor in this malady 
and there is little doubt that the physical basis of the disease 
is somewhere in the neighbourhood of the lenticular nucleus. 
Why on earth such an archaic part of the cerebrum should be 
such a common site of degeneration seems rather a mystery. 
Lundborg ascribes it to hypersecretion of the parathyroids. 
However, arteriosclerosis is a constant feature not to be neglected 
in attempting to establish the pathology. 

Treatment.—Probably every sedative under the sun has been 
tried for relieving the distress of paralysis agitans. Of these I 
have found trional, Cannabis indica and hyoscyamus the most 
useful. 


CHAPTER XXII. 


MENTAL DISORDERS OCCURRING IN ASSOCIATION WITH 
VISCERAL DISEASE. 


Ir is almost a truism that the higher functions of the brain 
are liable to be perturbed whenever the functions of the menial 
viscera become disordered through disease. If large portions 
of the lung be destroyed, the brain suffers from deficient aeration 
of its nutrient medium, the blood; in uncompensated heart- 
disease the brain is affected as much as, or more than, other less 
delicate organs by the inefficient circulation of the blood; if 
the kidneys fail to excrete toxic products, the brain must be 
injured by the effects of the retained poisons. These facts have 
long been recognized and in a bygone age, when the relation- 
ship was ill understood, mental disorder associated with visceral 
disease used to be called “‘ sympathetic insanity ’’. Since those 
days our knowledge of the relationship has been advanced by 
numerous investigators. We have already dealt with the 
delirium of fever, the post-febrile exhaustion insanities and the 
insanities associated with disease of the endocrine organs. In 
this chapter we have to consider the mental condition of patients 
suffering from phthisis, heart-disease, kidney disease and de- 
rangement of the digestive system. 

The most interesting contribution to this subject is con- 
tained in Dr. Head’s Goulstonian Lectures for 1go1. The 
observations recorded in those lectures have been neither con- 
firmed nor refuted by any subsequent observer, but there is no 
reason for doubting them. Dr. Head reports the occurrence of 
hallucinations of vision, hearing and smell in cases of phthisis 
and heart-disease. Hallucinations of vision are the most 
frequent; they usually take the form of a figure standing at the 
foot of the bed and are said to be lacking in colour. The halluci- 
nations of hearing do not take the form of voices; they are usually 
knocks or taps, bells, footsteps or heavy breathing. The smell 
hallucinations are of decaying matter, something burning, an 
earthy smell or the smell of gas. The patients are also liable 


to attacks of depression or suspicion. It is further stated that 
488 


PAIN CAUSING HALLUCINATIONS 489 


all these mental symptoms arise in association with severe or 
prolonged pain resulting from disease of the viscera and referred 
to the body-wall. In Dr. Head’s series of cases the symptoms 
occurred in phthisis, aortic regurgitation, aneurysm and dilated 
aorta, mitral regurgitation, combined aortic and mitral disease 
and in adherent pericardium. They do not occur in the absence 
of pain, e.g., in those cases of valvular disease in which the first 
sound is abolished or in cases of phthisis in which destruction of 
lung tissue progresses so rapidly as to destroy the pulmonary 
nerve-ends. Nor do these mental phenomena occur in association 
with the pain of pleurisy, the explanation given by Dr. Head 
being that this pain arises in the body-wall itself and is not a 
referred or reflected pain. It is obvious, in the light of our 
present knowledge, that all these symptoms are due to states of 
exhaustion and fever, which we have recognized to be especially 
provocative of hallucinations. 

It is further pointed out that pain referred to the abdomen 
is more liable to cause mental depression than pain in any other 
region. Hence it is found that the pain of aortic disease, which 
is referred to the upper part of the chest, is less frequently 
associated with mental depression than that of double mitral 
disease which is referred to the upper abdominal areas. 

Similarly with phthisis. In the early stages, when the disease 
is limited to the apices of the lungs, the patient is cheerful and 
hopeful of recovery (spes phthisica); but when the disease in- 
vades the lower lobes and the pain is referred to the abdomen, 
he becomes depressed and is fearful of impending harm. Later 
he becomes suspicious, thinks that others are talking about him 
and that the nurses do not like him and are inclined to neglect 
him. With inexperienced nurses this mental attitude is liable 
to lead to unfriendliness, complaints and even quarrels; but the 
phthisical patient’s last days may be made much happier if he 
be treated with the tactfulness which nurses are wont to extend 
to patients whom they recognize to be suffering from mental 
disorder. ) 

It is interesting to note that exactly the same mental symptoms 
occur in cases of tubercular peritonitis, but even in a more 
marked degree. 

The depression and train of neurasthenoid symptoms associated 
with enteroptosis are possibly to be accounted for in the same 
way, abdominal discomfort being especially lable to induce a 
state of misery and chronic nervous exhaustion. 

By the way, many cases of enteroptosis are due to dilatation 


490 MIND AND ITS DISORDERS 


of the stomach, which allows the colon to fall into the lower part 
of the abdomen. Again, many cases of gastric dilatation are 
due to anxiety states, the consequent adrenalemia inhibiting 
peristalsis and closing the pylorus and possibly the other intes- 
tinal sphincters described by Sir Arthur Keith. In such cases 
the visceroptosis should be treated as well as the anxiety state, | 
because it reacts on the nervous system and treatment of it 
frequently relieves many of the neurotic symptoms. A Curtis's 
belt and some gastric antiseptic, such as Dimol, give much relief; 
but some people recommend a surgical operation. 

Adrenalemia is also responsible for the high blood-pressure 
occurring in anxiety states. Craig found that a low blood- 
pressure is liable to be associated with motor restlessness. In 
accordance with this observation we find that attacks of excite- 
ment are common in patients whose blood-pressure is low, especi- 
ally those afflicted with aortic disease. Similarly in all cases of 
heart-disease, When compensation suddenly fails, motor restless- 
ness is an almost invariable concomitant. The same symptom 
is observed in cases of chronic renal disease when the blood- 
pressure suddenly falls as a result either of cardiac failure or of 
prolonged diarrhoea. On the other hand, we have all had patients 
with a blood-pressure of 250 mm. of mercury or more who are 
invariably happy and cheerful; but it must be admitted that 
they are usually depressed. I know of no treatment that will 
materially reduce such a high blood-pressure and, in my ex- 
perience, the life of such patients is destined to terminate within 
a couple of years. 

Uremia.—There is an acute delirious form of uremia in 
which occur many of the symptoms characteristic of acute con- 
fusional insanity of toxic origin. There are hallucinations of 
vision and hearing and the patient exhibits occupation delirium 
in which he is apparently busy at his usual work. There is 
difficulty of perception and it is impossible to distract the patient's 
attention from his hallucinations; if, however, one succeed in 
doing so, it is found that there is difficulty of perception, with 
disorientation in time and place. The memory is poor. The 
patient is restless and agitated and is liable to localized or general 
convulsions. 

When psychosis arises episodically during the course of chronic 
Bright’s disease, states of depression are more common than 
states of excitement, probably on account of the raised blood- 
pressure. According to Roubinovitch, Bright’s disease may be 
suspected of having etiological relationship to the mental dis- 


DIABETES 4QI 


order when the following symptoms are present: hallucinatory 
confusion; crises of hebetude, somnolence or stupor; cataleptic 
phenomena occurring independently of hysteria or, we presume, 
of dementia przecox; and convulsions or attacks of coma. 

Diabetes.—A relationship between this disease and insanity 
has long been recognized. It is not uncommon to find a history 
of mental disease among the relatives of diabetics, nor is it 
rare to find a history of diabetes among the relatives of the 
insane. Moreover, sugar may be detected in the urine of about 
I in 400 of the insane (Bethlem cases) excluding cases of true 
diabetes. 

The author has had eight cases of glycosuric insanity under 
his care. Six were cases of depression, of whom one died and 
five recovered under the ordinary treatment for diabetes; the 
seventh became a senile dement. The eighth case was compli- 
cated by alcoholism and was really a case of chronic hallucina- 
tory insanity. It is said that in some such patients the sugar 
disappears from the urine when insanity supervenes, and re- 
appears as soon as recovery from the mental disorder is estab- 
lished. In the author’s cases the sugar gradually disappeared 
under treatment, complete absence of glycosuria preceding by 
a considerable period restoration to mental health. 

Gout.—The characteristic irritability of a gouty patient during 
an acute attack of his disease is well known. Some gouty 
patients are liable to attacks of depression in association with 
their attacks of gout. In others, attacks of gout are said to 
alternate with attacks of insanity. 

Treatment is to be carried out on general medical principles. 


CHAPTER xecki ia 
IDIOCY AND IMBECILITY. 


(AMENTIA OR MENTAL DEFICIENCY.) 


THESE are states of arrested or retarded mental development 
occurring as the result of some disease or of injury to the child 
in utero or during the first few years of extra-uterine life. 

For practical purposes it is necessary to recognize that there 
are different grades of mental deficiency. The subjects. are 
accordingly classified into idiots, semi-idiots, imbeciles, semi- 
imbeciles or backward children, and moral imbeciles. 

Cretinism is elsewhere described (p. 423). 

Etiology.—Neuropathic heredity is regarded by many as the 
most important and most frequent cause of congenital weak- 
mindedness. 

It is said that illness, fatigue and especially drunkenness of 
the parents at the time of conception are liable to induce idiocy 
in the child, also that disease of the mother during pregnancy, 
especially in the earlier months, may lead to a similar result. 
Injury to the pregnant uterus, often by ineffectual attempts at 
abortion, is often regarded as another potent cause inasmuch as 
it is liable to interfere with the nutrition of the foetus. This 
last factor is held to be responsible for the frequent occurrence 
of idiocy among illegitimate children. 

We cannot but be sceptical respecting all these alleged causes 
of mental deficiency. The spermatozoa are extraordinarily well 
protected by mucus against the toxic products of disease, alcohol 
and any other poisons in the blood; and the ovary is not a 
particularly vascular organ. After conception, moreover, the 
embryo is even more cut off from and independent of the maternal 
circulation. Again, so serious an attempt at abortion as to 
interfere with the nutrition of the foetus would assuredly in most 
cases be very far from ineffectual. 

At birth the brain is liable to suffer injury if the child’s head 
is disproportionately large or the pelvic brim of the mother 
deformed or disproportionately small so that labour is unduly 

492 


CAUSES OF AMENTIA 493 


prolonged. For a similar reason we find that the incidence of 
idiocy among first-born children is abnormally great. There is 
no doubt that the pressure to which the child’s head is subjected 
during the process of birth causes retardation of mental develop- 
ment, even in normal cases; for it has been ascertained that 
children born by Cesarean section develop much more rapidly 
than those born in the natural way. They are months ahead 
of the latter before the end of the first year. On the other hand, 
the last child of a long series is liable to be weak-minded, the 
mother’s strength and nutrition having been exhausted by 
frequent pregnancies. 

Obstetric manipulations at birth have sometimes been held 
responsible for producing an idiot; but it is more probable that 
some deformity of the head of the child destined to become 
an idiot has necessitated interference on the part of the ob- 
stetrician. 

That idiocy is twice as frequent in boys as in girls is possibly 
to be correlated with the fact that the male head has greater 
difficulty in passing the pelvic outlet and is therefore more liable 
to injury at birth. 

Idiocy may occur as a sequel to some of the acute specific 
fevers. It is sometimes ascribed to a series of infantile con- 
vulsions: a more correct view of the relationship would probably 
be that the convulsions are symptomatic of an already existing 
degeneracy or morbid tendency of the nervous system. 

Most children who acquire organic disease of the brain during 
infancy remain mentally defective. These are cases of infantile 
hemiplegia, infantile diplegia, meningitis, encephalitis, cerebral 
hemorrhage, meningeal hemorrhage and diffuse or nodular 
sclerosis. A few cases are due to congenital syphilis. 

Lastly there remains to be mentioned the most important 
cause of all, epilepsy, which is responsible for about one-third 
of the cases. 

The etiology of mental deficiency has also been studied from 
a purely statistical standpoint, the investigators having an 
enormous amount of material at their disposal and exercising 
the greatest care in arriving at their conclusions. These, how- 
ever, are extremely divergent; for, on the one hand, Mott con- 
siders that mental deficiency is the terminal stage of degeneration 
of a family whose progenitors have suffered from the maniacal- 
depressive psychosis, dementia praecox etc.; while Rosanoff and 
Orr are of the opinion that mental deficiency is not related to 
insanity at all, but has hereditary features of its own. Although 


494 MIND AND ITS DISORDERS 


not above criticism, the writings of Rosanoff and Orr have 
proved the more convincing to the present writer and they are 
more in accordance with his impressions gained from a much 
more limited experience. These American physicians even go so 
far as to state that the heredity of mental deficiency is in accord- © 
ance with the Mendelian laws if mental normality be regarded 
as a dominant and mental deficiency as a recessive character. 
Here again, the evidence they adduce in support of this doctrine 
is rather convincing. 

Dr. C. S. Myers, the psychologist, has drawn attention to the 
fact that some cases are of definite psychotic origin, the child 
having developed a psychosis in early life which has interfered 
with subsequent mental development. 

Physical Signs.—These consist for the most part of the physi- 
cal stigmata of degeneration described in the chapter on that 
subject. They are numerous and of frequent occurrence in 
idiots, rather less numerous in imbeciles; but among both classes 
the stigmata occur with greater frequency than among the insane. 
Paralyses of various kinds are seen in the organic cases. 

Mental Symptoms—Sensation.—One form of idiocy, “ idiocy 
by deprivation of the senses’’, is entirely due to the patient 
having been either born deaf and blind or deprived of the senses 
of vision and hearing by disease in early life. Without special 
training such persons are destined to remain mentally deficient 
because those windows of the soul through which a normal 
person gains most of his experience of the outside world are 
permanently closed. These patients are of considerable interest 
in that it has been shown by praiseworthy tutors of exemplary 
patience that such subjects may attain a fair degree of mental 
development through education of the sense of touch alone. 
In such cases the senses of taste and smell receive no education 
but are used to indicate to the pupil what is to be regarded as 
pleasant or unpleasant. 

It is to be understood that not all blind deaf-mutes are cases 
of “idiocy by deprivation”’, but many exhibit the physical 
stigmata of degeneration and show evidence of cerebral as well 
as peripheral deficiency: such cases cannot be regarded as 
educable. 

Deaf-mutism is a condition closely allied to “‘ idiocy by depriva- 
tion ’’. Children who are born deaf naturally have no means of 
learning their native tongue and the knowledge that is to be 
gained thereby; they are therefore destined to become deaf- 
mutes. They may, however, be taught the deaf-and-dumb 


SYMPTOMS OF AMENTIA 495 


alphabet or, better still, lip-reading; and they may then be 
educated to such a degree that they scarcely miss the faculty of 
hearing. The condition is to be regarded as markedly hereditary 
and liable to occur in members of the same family, and especially 
in the collateral branches. Deaf-mutism is more prevalent in 
goitrous districts than elsewhere and it is three times as common 
among Jews as among Gentiles. 

Blindness invariably occurs in association with the congenital 
form known as “‘amaurotic family idiocy ’’: in these cases the 
blindness is not in any way a cause of the idiocy as in “ idiocy 
by deprivation ’’, but rather a concomitant symptom of degenera- 
tion of the nervous system. All the recorded cases have occurred 
in the offspring of Jewish parents. The child goes blind shortly 
after birth, the ophthalmoscopic appearances being a white patch 
in the region of the macula with a cherry-red spot in its centre. 
The process terminates in complete retinal and optic atrophy. 
This condition is associated with progressive general weakness, 
almost amounting to paralysis, and terminates fatally at about 
two years of age. 

The disease is liable to occur in several members of one family. 
Ireland stated that of twenty-seven recorded cases, eighteen 
occurred in twelve families. 

Apart from the cases of “‘ idiocy by deprivation ”’ and “‘ amau- 
rotic family idiocy ’’, blindness exists at birth or develops shortly 
after birth in about 6 per cent. of idiots and imbeciles, usually 
as the result of optic atrophy. Spasmodic squints and nystagmus 
from errors of refraction and other causes are even more common. 

Defects of hearing, taste and smell are much less frequent 
than those of vision. Defect of hearing is usually due, not to 
a cerebral lesion, but to malformation or disease of the ear 
itself. Although anosmia 1s uncommon, many idiots appear to 
be incapable of experiencing pleasantness and unpleasantness in 
association with odours. 

It is said that tactile, painful and thermal sensations are 
sometimes deficient in the severest forms of idiocy. I have 
not been able to verify this observation. On the contrary, 
I have observed that painful sensations (pin-pricks) appear 
to be normally appreciated by idiots, but that analgesia of the 
distribution described on p. 118 occurs sometimes in imbeciles. 
An imbecile girl, aged fourteen, whom I saw at Tooting Bec 
Asylum by the kindness of Dr. Beresford, could appreciate 
painful sensations in the groin and soles of the feet only. She 
was of sufficient intelligence to explain to me that, though she 


496 MIND AND ITS DISORDERS 


would not care herself to transfix a portion of her skin with a 
pin, the proceeding caused her no pain. She had sufficient 
mental capacity to be able to say the multiplication table up to 
‘HVE times ss 

Perception.—The perceptive faculties develop either late or © 
not at all. In some of the severest cases of idiocy in which 
there is no loss of sensation the patients never make use of their 
senses to gain knowledge of their environment. This is entirely 
due to want of development of volitional attention. They see, 
but they never look; they hear, but they never listen; cutaneous 
sensations are present, but they are not even localized. 

Inasmuch as the instincts and emotions are forms of reaction 
to percepts it is obvious that these reactions cannot take place 
in cases of extreme idiocy. Crying occurs, but this is probably 
a medullary reflex occurring as a response to painful stimuli; 
it is not a true emotional reaction to a percept. 

Severe cases of idiocy may be recognized shortly after birth 
when it is found that the infant does not seek or even suck the 
breast. The instincts are all late in appearing so that an idiot 
child ten years of age may be no further advanced in his develop- 
ment than a normal child of ten months. Both, for example, 
would be beginning to utter articulate sounds and to walk and 
both would still be “‘ wet and dirty ”’ in their habits. 

In children from whom the faculty of perception is absent 
there is of course no desire to eat or drink; left to themselves 
they would die of starvation. Similarly the desire to micturate 
or defecate is absent; evacuations of the bladder and rectum 
take place reflexly as in spinal paralysis. 

Idiots, like normal infants, are nearly always asleep. 

In imbecility the faculty of perception approaches the normal. 
Instinctive attention is present, but the power to attend volun- 
tarily is defective. The emotions and instincts develop normally, 
but, volition being weak, they are uncontrolled. Accordingly, 
we find, in agreement with the principles laid down on p. 148, 
that the imbecile has strong emotions and instincts. He is shy 
before strangers, so much so that in many institutions for weak- 
minded children it is customary to defer examination for a week 
or more in order to allow the patient to get over his shyness 
and to become accustomed to and more or less friendly with 
the doctor. Imbeciles form strong likes and dislikes and they 
are very affectionate towards those to whom they take a fancy. 
They are usually gentle and timid and feel punishment acutely. 

The instincts, in addition to being uncontrolled, are lable to 


—_ 


SYMPTOMS OF AMENTIA 497 


be perverted. Some imbeciles take a pleasure in striking or 
otherwise injuring creatures weaker than themselves, in breaking 
windows, stealing and indulging their sexual impulses. Lying, 
however, is not a common fault, for the imagination as a rule 
is not sufficiently developed. They can seldom be taught the 
full meaning of the difference between right and wrong; but 
fear of punishment is often sufficient to cause them to refrain 
from immoralities. 

The actions of imbeciles are instinctive impulses, imitative acts 
or the carrying out of simple orders. True volitional acts occur 
rarely. 

Ideation is mostly of the visual type, but many imbeciles and 
even idiots can remember musical airs. The train of thought 
(association of ideas) is of the scatter-brained variety owing to 
defect of voluntary attention. For the same reason associative 
memory is always defective. 

In many of the lighter grades of imbecility, however, the 
subjects show a remarkable memory for figures such as dates. 
Many of the “ calculating boys’”’ belong to this class. It is not 
known by what mental process they arrive at their results; usually 
the faculty disappears if they are taught ordinary arithmetic. 

Conception appears to be deficient. In the lighter grades of 
idiocy and the severer forms of imbecility the patient can form 
an idea, for example, of a chair; having got so far, he is in- 
capable of developing the abstract concept of a chair and of 
appreciating the difference between one chair and another. 
For him all chairs are the same. Much less is he capable of 
understanding the meaning of such abstract concepts as space, 
truth and virtue. 

With such deficiency of the power of abstraction and dis- 
crimination it need scarcely be added that the judgment is feeble 
and more than liable to be erroneous. 

The vocabulary of the imbecile is limited. He has names for 
common objects and a few adjectives but very few verbs, so 
that he rarely forms sentences. As with the lower classes in 
this country, adjectives have to do duty for adverbs. In con- 
formity with the egoism characteristic of the imbecile the pro- 
noun “‘ me ’”’ looms large. 

Difficulty of articulation is common. Lisping occurs in cases 
where the hard palate is so deformed that the tongue cannot 
be uniformly applied to the roof of the mouth. Stuttering and 
stammering are also fairly common. There is often difficulty 
in the pronunciation of the gutturals and of the liquids / and +. 

32 


498 MIND AND ITS DISORDERS 


Fic. 75.—R.R., AGED Io YEARS, AND HIS SISTER, T. R., AGED 14 YEARS. 
HIGH-GRADE GENETOUS IMBECILES (CAUSE UNKNOWN). 


VARIETIES TOF TDIOGY 499 


Some of these difficulties may be due to the large size of the 
tongue in many patients. 

A fair number of imbeciles may be taught to write, but the 
calligraphy is seldom good. It is puerile and they usually have 
difficulty in performing all the finer movements requiring precise 
co-ordination. 

Moral imbecility is chiefly characterized by deficient control 
of the instincts and a fondness for crime, while considerable 
cunning and deceit are usually exhibited to evade detection. 


Fic. 76.—HYDROCEPHALIC IMBECILE, AGED II. 


The egotism of the moral imbecile is unbounded and he is always 
a conceited braggart, a liar too of the first order. 

His memory is good and judgment fair. He is clever with his 
hands, especially at games, usually musical and often artistic, 
but incapable of applying himself steadily to a profession or 
trade. 

Moral imbecility, properly so called, is invariably accompanied 
by a certain amount of mental defect or backwardness in other 
ways; but this is always slight. Delinquency may be a symptom 
of imbecility; such a case is to be classed as an ordinary 
“mental defective’’. The diagnosis of moral imbecility is justi- 
fiable only when immoral tendencies far exceed the intellectual 


500 MIND AND ITS DISORDERS 


x 


defect. Not every case of delinquency is to be diagnosed as moral 
imbecility. Among the lower orders many children are brought 
up among thieves and other criminals; not only have they no 
chance of learning right from wrong, they are even taught to 
do what is wrong. These are not moral imbeciles. Again, some 
otherwise normal young people of the upper classes, brought up 
in apparently ideal conditions, find themselves occasionally 
impelled to commit petty thefts and other delinquencies—to 
their own horror and amazement. These are not moral im- 


Fic. 77.—Group OF MONGOLIAN IMBECILES AT THE FOUNTAIN 
MENTAL HospPITAL, TOOTING, 


No two are related to one another, as might be suspected. [Photograph by 
Dr. T. Brushfield. } 


beciles; their immorality is determined by some unconscious 
motive, some complex which can be unearthed by psycho-analysis 
so that the case is cured in about six months or even less. More- 
over, in appraising a case we have to take into consideration 
the habits of the class to which the delinquent belongs; for 
example, I have known a family of the lower orders to laugh 
on the occasion of one of their number giving birth to a child 
one week after marriage; but this would be no laughing matter 


VARIETIES OF IDIOCY 501 


to the family of a University professor. Lastly, we have to 
recognize that delinquency may be an early symptom of some 
psychosis, such as epilepsy or dementia preecox, and other signs 
of these diseases should always be sought. 

CLASSIFICATION.—The usually accepted classification is that of 
the late Dr. Ireland, which is based as far as possible on etiological 
and pathological considerations. 

Genetous idiocy is the name given to states of weak-minded- 
ness due to pathological changes in the brain which have taken 
place before birth but cannot in the state of our present know- 


Fic. 78.—MICROCEPHALIC Ip1IorT. 


Circumference of head—=16 inches. 


ledge be diagnosed before a post-mortem examination is made. 
Many of the other varieties of idiocy may be of congenital origin, 
but inasmuch as a diagnosis of the cerebral lesion can be made 
before death they are not included in this class. 

Among genetous idiots Ireland included the amaurotie family 
idiots and also those known as Mongolian idiots, a large class 
presenting many of the physical stigmata of degeneration and 
so called because of their facial resemblance to the racial Mongol, 
the palpebral fissures sloping downwards and inwards. Epi- 
canthus and nystagmus are common. The face and back of the 


502 MIND AND ITS DISORDERS 


head are flattened. The tongue is abnormally long and often 
fissured, but this fissuring is not present at birth. The hands 
and fingers are soft and stumpy, their ligaments are lax and the 
palms show innumerable lines running in all directions. Their 
stature is small, mainly owing to shortness of the legs, and they 
exhibit a curiously straight back, while the abdomen is rather 
prominent. Their articulation is invariably defective. Mon- 
golian idiots are especially liable to a form of mucous diarrhcea 
which occurs in the congenitally weak-minded. Dr. Rankine, 
a former medical officer of the Earlswood Institution, described 
a form of cataract in these patients. The pathology of Mongolism 
is unknown; the endocrine system is naturally suspected, but 
investigation of it has so far proved negative. Another group 
have been called Aztee idiots because of their facial resemblance 
to the Aztecs. 

Microcephalie idiocy is idiocy existing in an individual, the 
circumference of whose head is less than 17 inches (18 accord- 
ing to some authorities). The smallness of the head is due to 
smallness of the brain and not to premature ossification of the 
cranial sutures as was supposed by Lannelongue when he pro- 
posed the operation of craniectomy to allow the brain to expand. 
This operation was performed on many microcephalic idiots 
without effecting a single cure. Indeed in some cases the head 
grew smaller as a result of the operation. 

Hydrocephalic idiocy is caused by atrophy of the brain sub- 
stance from pressure by an excessive accumulation of fluid 
within the lateral ventricles, the foramen of Magendie being 
closed. The circumference of the head is enormously increased. 
In the congenital form the ventricles are elongated; in the ac- 
quired form they are increased in their vertical and transverse 
diameters. At least some of these cases are due to congenital 
syphilis. A few cases of hydrocephaly exist in which there is 
apparently no impairment of intellect. 

In hydrocephaly the greatest increase takes place at the temples 
and the distance between the eyes is increased. The head is 
globose. This feature serves to distinguish it from the rarer 
condition of inflammatory hypertrophy of the brain, in which the 
greatest increase is above the superciliary ridges. 

Eclampsie idiocy is the name applied to those cases in which 
the state of weak-mindedness is ascribed to a series of fits occur- 
ring during the first year of life, generally during teething. It 
seems doubtful whether such cases merit the distinction of a 
separate class. The probability is that they are genetous idiots 


VARIETIES OF IDIOCY 503 


whose first symptom of cerebral weakness is a series of teething 
convulsions. 

Epileptic idiocy exists as well as epileptic insanity, and it is 
desirable to draw between the two a distinction, which is bound 
to be based upon the age at which the mental faculties first 
show signs of degeneration. Dr. Ireland fixed this age at seven 
years. 

Epileptic idiots can scarcely be regarded as educable. The 
usual course is that they acquire a certain amount of knowledge; 


Fic. 79.—HYPERTROPHIC IMBECILE. 


Circumference of head =29 inches. 
Binauricular diameter ==124 inches. 
Antero-posterior diameter = 12} inches. 
Width of forehead = 4} inches. 


then there comes a series of fits which obliterate that knowledge 
and the teacher has to begin all over again, only for the same 
process to be repeated time after time. 

In the chapter on epilepsy it will have been noticed that we 
are at last beginning to understand the disease, but I doubt 
whether even Dr. Pierce Clarke’s methods will ever be of much 


service to the epileptic imbecile. 


504 MIND AND ITS DISORDERS 


Epiloia is the name given to a group of cases of mental defect 
associated clinically with a chronic affection of the skin (adenoma 
sebaceum), epileptic fits and albuminuria. The cutaneous affec- 
tion is commonly limited to the face, but it may appear on the © 
chest and other parts of the body. Post-mortem adenomatous 
tumours, similar to those in the skin, are found in the cortices. 
of the brain and kidneys. 

Incomplete cases occur in which adenoma sebaceum is a pure 
skin disease without mental defect and there may be cutaneous 
lesions with mental defect in which no convulsions occur. 


Paralytic idiocy is due to coarse lesions of the brain, usually 
hemorrhage or thrombosis occurring at birth or during early 
infancy. It is associated as a rule with hemiplegia; but many of 
these patients are paralyzed on both sides of the body (diplegia). 

Inflammatory idiocy occurs as the result of a chronic en- 
cephalitis. According to Ireland it is usually a sequel to one of 
the acute specific fevers. In one form of the disease (hyper- 
trophic idiocy) the head becomes enlarged owing to an abnormal 
increase in size of the whole brain. There is an increase of all 
its constituents, not of neuroglia only; but the higher functions 


VARIETIES OF IDIOCY 505 


suffer on account, it is said, of an increased intracranial pressure 
caused by the unyielding bony framework of the skull. If this 
be so, the operation of craniectomy might be revived for these 
cases. 

Sclerotic idiocy is due, as its name suggests, to sclerosis of the 
brain. It may be recognized by the occurrence of spasms ~ 
affecting particular groups of muscles, which sometimes pass 
into general convulsions. The sclerosis may be either diffuse or 
tuberose and it may lead either to atrophy or hypertrophy of 
the cerebrum. The frontal and occipital lobes are usually 
affected more than other parts of the brain. 

True Syphilitie idiocy is rare, despite the fact that some in- 
vestigators have reported that the Wassermann reaction is posi- 
tive in rather a large proportion of the mentally deficient. The 
diagnosis depends on the usual signs of congenital syphilis, such 
as a flat bridge to the nose, scarring at the angles of the mouth 
and, later, notched permanent central incisors and interstitial 
keratitis. 

Idiocy by deprivation of the senses has already been referred to. 

Binet and Simon approached the problem of classification from 
an entirely different standpoint, and conceived the notion of 
comparing mental defectives with normal children of different 
ages and assigning them to different “‘ mentalities’. Thus an 
imbecile of any age, possessing only the intelligence of a child of 
five, is said to be of “‘ mentality 5 ’’, and a defective, whatever his 
age, of the intelligence of a child of nine is assigned to “‘ mentality 
g’’. Those whose mentality is less than 3 are called “ idiots ”’; 
those with mentalities 3 to 7 are called “‘ imbeciles ’’; those with 
mentalities 8 to 12 are called ‘“‘ morons ’”’; while adults of mentali- 
ties 12 to 15 are regarded as “‘ backward ”’ or “‘ weak-minded ”’. 

Otherwise, an idiot is defined as a person who never learns, 
through defect of intelligence alone, to communicate with his kind 
by speech; an imbecile is one who, owing to defect of intelligence 
alone, fails to learn how to communicate with his kind by writing 
or reading; and a moron is a person who can communicate with 
his kind by speech or writing, but, owing to defective intelligence, 
shows a retardation of two or three years in his school studies. 

Of course, these terms are inapplicable when a child’s mentality 
is the same as his age. Moreover, some margin must be allowed 
for social status, education etc. 

To ascertain a person’s mentality Binet and Simon have devised 
certain tests which can only briefly be given here. For details 
the reader is referred to ‘““ A Method of Measuring the Develop- 


506 MIND AND ITS DISORDERS 


ment of Intelligence of Young Children ”’ (Chicago Medical Book 
Co., Chicago) and “‘ Mentally Defective Children” (Edward 
Arnold, London). Both are translations of works by Binet and 
Simon. 

The series of tests used in the method, grouped according to 
age, is as follows: 


Three Years. 


Shows nose, eyes and mouth. 
Repeats two digits :—7-5. 
Enumerates objects in a picture. 
Gives family name. 

Repeats a sentence of six syllables. 


Four Years. 
Gives own sex. 
Names key, knife and penny. 
Repeats three digits :—4-9-6. 
Compares two lines (Fig. 81—first pair). 


Five Years. 


Compares two weights. 

Copies a drawing of square... 7 2... . 2-1-0 eee 
Repeats a sentence of ten syllables. 

Counts four pennies. 


Six Years. He 
Distinguishes between morning and afternoon. 
Defines in terms of use. ( 
Copies a'lozenge-shaped figure, /.. 7.5 ee \ j 
Counts thirteen pennies. . 
Compares faces from the esthetic point of view 
(Fig. 82; three pairs). " 


Seven Years. 


Can point to right hand; left ear. 

Describes a picture. 

Executes three commissions (e.g., “‘ Put this key on that chair; 
Close the door; and Bring me that box ’’). 

Gives values of nine sous, three of which are double (half- 
pennies and pennies). 

Names four colours (red, yellow, blue and green). 


N 

es ‘jenba oq 03 pezrusodal o1¥ sited 4se] 9914} 94} Jo OM} UBYM passed oq 
0} PeLapISUOd ST 4s9} BY], “UOTJSASdNs STY} JSISOI IDAO IO ZI AjI[eJUSU JO S[eNPIAIpUy ‘Y4Susyz [enba jo ore saury oy} YoryM 
ur sired 9914} I9MOT oY} JO 9UIeS OY} Avs 01 AOUAPUd} & ST 9I9Y} PUP 19] 94} UeY} I9SUOT ST JYSt1 oy} sired 9914} 4sIY 9YW 
UL ‘OM} 94} JO IasUOT 94} ST YOIYM payse soutwrexe oy} pue ioded jo sjoays o}e1edas uo patdoo aq prnoys souty jo sited oy] 

"19 ‘DI 

22) 

oe. 

) 

ea) 

fe 

7, SA AS ATR St SET EE TE IE IBLE. IE ET TIE ST EE CE: I IE ET 

je) 

= 

— 

A . 

fH a ———— 

ea 

Zz 

_ 

= 


508 MIND AND ITS DISORDERS 


Eight Years. 


Compares two remembered objects—e.g., a fly and a butter- 
fly. (Two differences should be given.) 

Counts backwards from 20 to o. 

Indicates omissions in pictures (Fig. 83). 

Gives day and date. 

Repeats five digits (e.g., 5-7-3-2-4). 


a he ae Ve q As 
oy PSR 
ee > om = 71 ) 
ai Ve. 7, 3 yf 
& eed, " abs 
Deve! ) 
aa 
fy 1S 
ne ) — 
ay ) Y [ . 


Fic. 82.—v. MENTALITY 6. 


Irom Dr. Drummond’s translation of ‘‘ Mentally Defective Children”’, 
by Binet and Simon. (Arnold, London.) 


BINET-SIMON TESTS 509 


Nine Years. 


Gives change from a shilling in mixed coins in the guise of a 
game. 

Defines in terms superior to use. 

Recognizes all the pieces of our money. 

Enumerates the months. 

Gives rational answers to easy questions (e.g., ““ What would 
you do tf you broke something belonging to somebody 
cise? '). 


Fic. 83.—v. MENTALITY 8. 


From Dr. Drummond’s translation of ‘‘ Mentally Defective Children”’, 
by Binet and Simon. (Arnold, London.) 


510 MIND AND ITS DISORDERS 


Ten Years. 

Arranges five weights in order. 

Copies drawings from memory. 

Criticizes absurd statements (e.g., ““Why 1s there always 
a yellow dog when two men quarrel in the street ?’’). 

Gives rational answers to difficult questions (e.g., “ Why. 
should you judge a person by Mus acts rather than his 
words ?’’). 

Uses three given words in two sentences. 


Twelve Years. 


Resists suggestion (length of lines) —Fig. 81. 

Composes one sentence containing three given words. 

Says more than sixty words in three minutes. 

Defines abstract terms, such as charity, justice, kindness. 

Discovers the sense of a sentence the words of which 
are mixed (e.g., “‘ For-an-the-at-hour-early-we-country - 
started ’’). 


Fifteen Years. 


Repeats seven digits. 

Gives three rhymes with the same word (e.g., meet). 

Repeats a sentence of twenty-six syllables. 

Interprets a picture. 

Solves a problem from several facts, e.g. : 

“My neighbour has just received some singular visitors. 

He received one after the other: a doctor, a lawyer and a priest. 
What is going on at my neighbour’s ?”’ 


ADULT. 


A sheet of paper is folded in four, and a small triangle is cut 
from the folded edge. The examinee draws the paper as he 
supposes it would appear if unfolded (Fig. 84). 

A visiting-card is cut diagonally (Fig. 85). 

The examinee is required to draw the figure which would 
appear if the lower triangle were turned over with A C applied 
tO seb and Gro: 

Gives differences of meaning of abstract terms—e.g., laziness 
and idleness. Gives three differences between a president of a 
republic and a king. 


BINET-SIMON TESTS 511 


_ Gives the meaning of a simple philosophical paragraph which 
has been read to him. 

Binet and Simon realize that their tests elicit only one impor- 
tant feature of mental deficiency. Otherwise the mentally defec- 
tive does not resemble in many ways a normal child. However 
skilful his teacher may be, the imbecile will never progress at the 


Fic. 84. 


BiGe OS: 


same rate as a normal child younger than himself, and he will 
never reach adult mentality. Further, the imbecile has lived 
longer than the normal child, and has therefore acquired more 
knowledge in certain directions; for example, his vocabulary is 
larger and he may even have achieved some acquaintance with 
a foreign tongue, usually French. In short, his knowledge is ill- 
balanced. 


512 MIND AND ITS DISORDERS ~ 


Again, the mentally deficient exhibit such traits as defects 
of speech and peculiarities of reasoning, comprehension and 
imagination, which do not occur ina normal child. After passing 
their mentality test, for example, they are lable to turn away 
and talk a lot of nonsense, quite unlike a normal child of the 
same mentality. Also we have to consider certain vicious ten- 
dencies, garrulity, unruliness and lack of attention, which are | 
not observed in the normal child. 

Criticisms that have been offered of the Binet-Simon tests are 
that the mentalities given for some of them are not applicable 
to English and American children, also that there is meagreness 
of tests for the higher and lower mentalities. Accordingly they 
have been revised and amplified, especially by Stanford and 
Termanin America. There are many other systems of intelligence 
testing; but they all result in recording the intelligence quotient 


or I O ofa patient, that is age In Yeats A child is to be regarded 


mental age 
as mentally deficient if the I O is lower than 0°75. 

Morbid Anatomy.—The lesions found in the brains of idiots 
are too numerous for detailed description in a work of this nature. 
. In addition to microcephaly, hydrocephaly, cerebral hyper- 
trophy and sclerosis mentioned above we meet with malforma- 
tions of the brain, such as abnormal arrangement of the convolu- 
tions, microgyria, pseudo-porencephaly (cysts marking the site 
of old hemorrhages), local atrophies and atrophy of the cerebral 
hemisphere of one side with or without atrophy of the cerebellar 
hemisphere of the opposite side. In some rare cases there is 
complete absence of one or more convolutions, the arachnoid 
bridging over the gap while the pia mater lines a funnel-shaped 
opening into the lateral ventricle and becomes continuous with 
the ependyma (true porencephaly). In some rarer cases the 
corpus callosum is absent. 

Prognosis.—Idiots and imbeciles can never attain the mental 
capacity of normal individuals; but by suitable training many 
are capable of considerable improvement, sufficient in some 
cases to enable the patient to earn his own living. It is difficult 
to frame rules applicable to every case whereby it may be deter- 
mined whether a child is educable or not. Each case has to be 
considered on its own merits. The following principles, however, 
may be considered fairly safe guides :— 

Extreme forms of idiocy in which there is complete absence 
of perception and instinctive attention are absolutely incurable 
(mentalities I and 2). Little hope of improvement need be 


TREATMENT OF AMENTIA 513 


entertained of patients who suffer from convulsions from time 
to time or of idiots with a history of convulsions during the 
first two years of life. Little improvement can be expected in 
‘wet and dirty ”’ cases. Extreme emotional reaction generally 
means that the child cannot be taught much. The prognosis 
is bad if he is unable to walk. Lastly if he does not experience 
the sense of hunger and the desire for food, if at meal-time he 
does not care whether he receives food or not when he sees it 
passed round to others at the table, there is not much probability 
of his ever being educated. 

Puberty is apt to be a trying time for the imbecile; he is liable 
then to undergo a certain amount of temporary retrogression 
or to develop dementia przecox. 

Idiots seldom live long owing to their low power of resistance 
to disease. It is said that they are peculiarly liable to phthisis; 
but this opinion is not held by those in charge of idiot estab- 
lishments where the sanitary arrangements are unfavourable for 
infection. 

Treatment.—It is essential that idiots and imbeciles should 
live under very hygienic conditions. They should be warmly 
clad and their clothes should be cut in such a way as to conceal 
their deformities. When possible the habit of cleanliness should 
be enforced and control of the instincts be taught by means of 
firm but kindly discipline. 

The senses require to be cultivated by appropriate means into 
the nature of which we cannot enter here. Co-ordination of 
movement may be developed by various devices, such as getting 
the child to stand on a ladder and hold on to one of the rungs, 
by simple games and gymnastic drill which may be set to music. 
After some years it is often possible to teach a simple trade. 

In the education of these patients it is not to be expected that 
they will attain any degree of learning. If they can be taught 
to make themselves useful at a trade such as shoe-making, 
tailoring, gardening or, for women, laundry, sewing or house- 
work, that is all that is required to make them happy and more 
or less self-supporting. For them reading and writing are 
“extras ’’ as much as Latin and Greek to the ordinary school- 
boy; but many acquire these extras and can even do a little 
arithmetic. 

It ought to be added that education of the mentally deficient 
should be assigned to teachers specially qualified for the task. 
It must not be supposed, for example, that the ordinary methods 


of education of a child of six are applicable to an imbecile of 
33 


514 MIND AND ITS DISORDERS 


mentality 6. The two children* are comparable only in the 
sense suggested by Binet and Simon. Left to itself, the child 
of six would educate itself, as has been demonstrated by Dr. 
Montessori; but, paradoxical as it may seem, although her method 
of education is based on that used in establishments for the 
mentally deficient, they are not strictly applicable to these cases. 
The mentally defective require an education specially adapted to 
mental deficiency. } 


* In establishments for the mentally deficient the inmates are always 
called “‘ children’’, whatever their actual age may be. 


CHAPTER 2OX1V. 
COMBINED INSANITIES. 


IN an earlier part of this manual it was pointed out that the many 
functions of the mind are interdependent and that our study of 
them as separate forms of mentation is merely for convenience. 
Much more should any particular classification of mental disorder 
be regarded as merely convenient in the light of existing know- 
ledge. It should therefore not surprise us to meet occasionally 
with cases which can only be explained by referring them to two 
or more of the insanities described in this volume; for, on the one 
hand, identically the same etiological factors may be responsible 
for symptoms of different mental disorders in the same patient 
and, on the other, he may have been exposed to the various 
causative agents of several mental disorders. 

To take an extreme example: a man aged fifty-three, previously 
to the onset of his illness, suffered from occasional epileptic fits. 
While in West Africa he became infected with dysentery and had 
an exhausting diarrhcea for three months. The dysentery was 
cured at the Dreadnought Hospital, Greenwich, whence he was 
transferred to Bethlem. On admission he was found to have 
extensive anesthesia and hallucinations of vision and hearing. 
There was also a history of a severe blow on the forehead during 
a tram accident shortly before his illness. The degree of his 
disorientation of time and place may be gathered from the fact 
that he thought that the year was 1815, and that he was in 
Melbourne, Toronto or Pernambuco. His perception was so 
deficient that, although he was lying in bed, he believed that he 
was in either a theatre or a church. He did not know his own 
name, could not recognize his wife and his memory was a blank. 
Here we have to do with an insanity in which are present the 
combined results of epilepsy, intoxication, exhaustion and head 
injury. 

The study of these combined psychoses is yet in its infancy 
and it is impossible at the present time to give a detailed account 
of them; but it is hoped that the following remarks will help 

235 


516 MIND AND ITS DISORDERS 


the student to understand these difficult cases and to avoid error 
in diagnosis. 

Maniacal-Depressive Cases.—With these the most common 
complications are exhaustion symptoms; so much so that in the 
description of the intermittent and periodic psychoses reference — 
to such symptoms was found to be unavoidable. 

It will be remembered that the cardinal symptoms of intoxica- 
tion of the nervous system by the products of exhaustion and 
by many other poisons are analgesia, hallucinations, imper- 
ception, disorientation in time and place and loss of memory. 
Now when a patient suffering from mania or melancholia also 
presents any of the above symptoms the case cannot be regarded 
as uncomplicated. Cases of maniacal-depressive insanity with 
analgesia, hallucinations or both should be described as mania 
(or melancholia) with exhaustion symptoms. Analgesia and 
hallucinations do not occur in an uncomplicated maniacal- 
depressive psychosis, anergic and post-maniacal stupor being 
excepted. 

When exhaustion (confusional) symptoms complicate an attack 
of mania or melancholia the illness must be expected to last much 
longer than it otherwise would. Hallucinations, especially cf 
hearing, are of grave significance in melancholia, but are of minor 
import in mania. Analgesia is not so serious a symptom as 
hallucination, provided it is not prolonged for more than a 
month after the patient comes under treatment. Catatoniac 
symptoms are occasionally met with as a complication of 
maniacal-depressive insanity. 

Maniacal-depressive insanity appearing for the first time late 
in life is hable to be complicated by early symptoms of chronic 
cortical atrophy. There may be a slight degree of imperception, 
loss of memory for proper names and for quite recent events, and 
a tendency to eroticism. Insight js apt to be deficient. The 
presence of arteriosclerosis does not materially affect the prog- 
nosis of mania, but melancholia is not likely to be cured when 
the cerebral arteries are diseased. 

Exhaustion Cases and Dementia Precox.—Acute confusional 
insanity is sometimes complicated by cataleptic and catatonic 
phenomena to such an extent as apparently to justify the diag- 
nosis of dementia preecox., .On the other hand, dementia preecox 
may be complicated by exhaustion symptoms. If the patient 
is completely disorientated I generally regard the case as being 
primarily one of acute confusional insanity, the catatonic and 
cataleptic phenomena being secondary. Under such circum- 


COMBINED INSANITIES 517 


stances the prognosis is good, provided that the treatment is 
apt and persistent. The illness usually lasts about a year. If, 
on the other hand, disorientation is slight and especially if the 
patient shows a tendency to keep one hand constantly over the 
external genitalia I regard the case as being primarily one of 
dementia precox, the prognosis being hopeless. These, of course, 
are mere working rules; they are not infallible. 

Alecoholie Cases.—The student must be prepared to meet with 
cases which at first present the symptoms of an acute form of 
alcoholic psychosis and subsequently turn out to be examples 
of a chronic psychotic form, when the effects of acute intoxica- 
tion have passed away. Similarly he must be prepared to meet 
with cases which present symptoms of alcoholic insanity on 
admission and subsequently turn out to be cases of intermittent 
insanity, dementia precox, general paralysis, arteriopathic 
dementia; neurasthenia, epilepsy or some other mental disorder; 
the symptoms having, during the first few days, been masked 
by alcohol. 

Neurasthenies frequently have paranoid symptoms or morbid 
fears and vice versa, obsessional cases sometimes have some 
neurasthenic symptoms. 

Lastly it must not be forgotten that attacks of mania, melan- 
cholia, anergic stupor, collapse delirium and acute confusional 
insanity may and do occur from time to time among imbeciles, 
paranoiacs, epileptics, neurasthenics and others. In all such 
cases we must expect the one disorder to be modified by the 
other. It is only necessary for the student to recognize the 
possibility of these combinations in order to be prepared for 
them when they occur. 


CHAP FERS V= 
FEIGNED INSANITY. 


INSANITY is sometimes feigned by criminals with the object 
of escaping punishment, by soldiers and sailors in the hope of 
obtaining discharge from the services, by others seeking to 
evade duty or legal obligation imposed on them by a contract 
into which they have entered, by hysterical patients seeking 
sympathy and, in rare instances, by enterprising newspaper 
reporters who, in search of copy, endeavour by this means to 
gain admission to an asylum. 

During the War mental experts had a large experience of 
cases of malingering in men seeking a medical certificate to 
support an application for exemption from military service, 
mostly men of a certain class of a certain race. Imbecility was 
generally their choice. 

In such cases a medical man may be called to determine whether 
the mental disorder is real or assumed. When, under these 
circumstances, he is confronted with a subject suspected of 
malingering he should frankly make the object of his visit known 
and, if there is any detective work to be done, this should be 
relegated to an observant and intelligent attendant. 

A careful history of the mental symptoms must be taken. It 
should be noted whether there is any motive for malingering 
and, if so, what was the temporal relationship of the mental 
symptoms to the motive. It is also to be ascertained whether 
there were any premonitory symptoms of mental disorder, 
whether it developed suddenly and whether there were any 
previous signs of ill-health. Due attention should be paid to 
any history of previous mental disease in the subject or his 
family. 

Several visits are usually necessary before coming to a decision. 
The patient should be examined for the usual physical concomi- 
tants of mental disease, such as physical stigmata, furred tongue 
and disordered digestion with consequent refusal of food, and 
constipation. 

In uncomplicated cases the diagnosis is easy, the chief charac- 
teristics of feigned insanity being (1) incongruity of symptoms, 

518 


FEIGNED INSANITY 519 


(2) exaggeration of symptoms (they are overdone) and (3) ten- 
dency of the subject to show any symptom which appears to be 
expected of him. One mode of eliciting the last tendency is to 
remark in the patient’s hearing that there would be no doubt 
as to his insanity if such and such a symptom were present. 
The ruse is not often successful; but, in some cases, the said 
symptom makes its appearance at the next visit. 

The diagnosis is not always a simple matter; for insanity is 
sometimes simulated by those who have previously had an attack 
of mental disorder or, at the time of examination, exhibit symp- 
toms of undoubted mental instability. Indeed, we have to be 
prepared for subjects who are really suffering from one form of 
insanity but simulate another. 

As the reader has learned from previous chapters, insomnia 
is a common feature of the acute forms of mental disorder; but 
a malingerer sleeps soundly for many hours at a time, especially 
if he has set himself the task of simulating acute mania or some 
other form of motor excitement. 

The simulation of anzsthesia is readily detected and usually 
arrested by faradism with a wire brush. 

If a malingerer feigns imperception when he is asked to recog- 
nize common objects, he makes more stupid mistakes than those 
of a patient who is really suffering from imperception. He may, 
for example, call a coin a watch and a pencil a key. Hallucina- 
tions are seldom feigned unless they are suggested to the subject. 

Amnesia is a symptom which easily lends itself to simulation 
and is therefore often feigned. The malingerer, however, usually 
makes the mistake of introducing this symptom among others 
with which it is incompatible. He will, for example, feign acute 
mania with loss of memory for remote instead of recent events. 
He will remember trivial factors of an incident, such as a crime 
which he has committed, but will pretend loss of memory of the 
most important factor, viz., the crime itself. 

When delusions are feigned the malingerer gives expression to 
them obtrusively; a patient who is really deluded keeps them 
in the background. Again, feigned delusions change from day 
to day, being sometimes expansive, sometimes depressive. It 
may usually be observed, too, that the delusions are at variance 
with the subject’s conduct. Delusions of persecution are fre- 
quently selected; most of my war cases added them to their 
feigned imbecility. 

Motor excitement corresponding to the popular conception of 
“raving madness ” is sometimes feigned; but nobody can main- 


520 MIND AND ITS DISORDERS 


tain such excitement hour after hour and day after day like a 
person who is really insane; the work is too hard. Similarly 
the malingerer sets himself a difficult task if he attempts to be 
incoherent in speech; the deception can only be kept up for a 
minute or so. : 

The conduct of a malingerer is most faulty and ridiculous 
when he is under ostensible observation; it is normal when he 
thinks he is unobserved. An insane patient, on the contrary, 
tends to pull himself together when he is being observed. 

Simulation of melancholia is infrequent. Indeed, the malin- 
gerer rarely attempts to feign any particular insanity; he merely 
wishes to be thought “ mad”’ and takes no account of the fact 
that the modern study of mental disease has reached such pre- 
cision as to render detection fairly easy. 


CHAPTER OAAVE: 


SOME DISEASES TO WHICH THE INSANE ARE 
ESPECIALLY LIABLE, 


PHTHISIS. 


THE death-rate from phthisis in our large county asylums, as 
compared with that in the general community, is so alarming 
that some years ago the Medico-Psychological Association 
appointed a special committee ‘“‘ to make some practical sugges- 
tions for the isolation of phthisical patients in asylums’’. This 
action of the Association was the direct outcome of a prize essay 
by Dr. F. G. Crookshank, ‘“‘ On Phthisis Pulmonalis in Asylums ”’ 
and a paper by Dr. Eric France on “ The Necessity of Isolating 
the Phthisical Insane ’’. 

Dr. Crookshank pointed out in his essay that, although not 
more than 7-5 per cent. of the insane are phthisical on admission, 
the official death-rate from phthisis among the insane, which is 
probably too low by one-third or one-half, is 14:6 per 1,000 of 
the average resident population in English asylums; whereas 
the phthisis death-rate among the general population of England 
and Wales is 1-46 per 1,000 living. In other words, death from 
phthisis is ten times as frequent in asylums as it is among the 
general population. 

The causes of the frequency of phthisis in asylums are not 
far to seek; for it is found, on examination, that in most of our 
large county asylums every etiological factor is at work. 

In the first place it has been pointed out by Dr. C. J. Shaw, 
Medical Superintendent of Montrose Asylum, that the insane 
are, as a Class, more liable to tubercular infection than the sane, 
their capacity of resistance to tubercle, as estimated by the 
opsonic index, being deficient (0:8 to 0-9). The opsonic power 
is especially deficient during the acute stages of mental disorder 
and in cases of dementia praecox and general paralysis. 

Further, the respiration of depressed and demented patients, 
who form the majority of an asylum population, is shallow and 


infrequent. Not only is the characteristic favourable to the 
521 


522 MIND AND ITS DISORDERS 


development of phthisis; it renders early diagnosis difficult. 
With such patients the physical signs of phthisis may be so 
trifling as to lead the medical officer to the conclusion that he is 
dealing with an early case, whereas it is found at the autopsy 
a few weeks later that the lungs are riddled with cavities. 
Certainly it is impossible to diagnose phthisis in such patients 
as early as in a sane individual. | | 

Other potent factors in the causation of phthisis in county 
asylums are underfeeding and overcrowding, enforced upon 
medical superintendents by lay committees with excessively 
economical tendencies, and countenanced even by the Board of 
Control. 

“Under the most favourable circumstances, the floor-space 
allowed by the Commissioners corresponds to only 1,800 cubic 
feet of air per hour for ordinary patients (instead of 3,000),* 
and for sick patients to only 2,376 instead of the needed 3,000 
to 4,000.* On their own estimate, overcrowding existed, on 
January 1, 1898, in thirty-six out of the seventy-seven county 
and borough asylums. In these thirty-six asylums there was, on 
the estimated dormitory and single-room accommodation, over- 
crowding to the extent of 1,486 persons.” “It is childish to 
assert that half a crown or less per week is enough to spend on 
food.” “ Surely it would be difficult to find institutions which 
afford such opportunities for the dissemination of phthisis germs 
as do our asylums. Consider a community existing under condi- 
tions that preclude, for many, adequate exercise in the open air; 
spending long hours in overcrowded day-rooms and dormitories ; 
a community of filthy and careless habits, and already phthisical 
in the proportion of 15 to 25 per cent. Such a community is 
formed by the inmates of every county asylum ”’ (Crookshank). 

The Tuberculosis Committee pointed out that the occupation 
of hair-picking in the upholsterer’s shop is a dangerous one, 
having regard to phthisis. Not only are sharp-pointed particles 
of hair-dust liable to be inhaled and to wound the lung, but the 
hair is itself liable to be impregnated with tubercle bacilli. 

The Committee found that the death-rate from phthisis was 
higher in asylums built on bad and damp soil than in those built 
on good and dry soil. They also remark on the unsatisfactory 
heating and ventilation of many asylums. 

The remedies are obvious. In the first place more cubic space 
must be allowed for patients. It is held that this should not 
be attained by building larger establishments, but by more 


* Parkes’s standard. 


PHTHISIS IN ASYLUMS 523 


strictly limiting the number of patients in asylums not larger 
than those already in existence. It is further held that not more 
than fifty patients should sleep in the same dormitory, however 
large. With competent nurses, properly trained, the air in a 
dormitory can easily be changed as often as four times in an hour 
without undue draught. During the day every aperture by 
which air can gain access to the dormitory should of course be 
opened to its fullest extent. Similarly an intelligent attendant 
can change the air in the day-rooms five or six times an hour 
without undue draught and surely it is possible, by a little 
thoughtful organization, to arrange that every patient not under- 
going bed-treatment should have a minimum of four hours daily 
in the open air, weather permitting. 

Patients should be restrained as much as possible from the 
dirty habit of spitting on the floor of the ward or on the ground 
of the airing-court. The Tuberculosis Committee suggested 
that a wide-mouthed cup with contracted neck and containing 
some disinfectant might be fastened to the wall by a padlocked 
band. Any sputum found on the floor should be immediately 
wiped up with a rag, and this immediately burned. Hair, coir 
and flock should always be disinfected before they are sent to 
the upholsterer’s shop. 

The diet ought to be more generous than at present. In view 
of the importance of a liberal diet, not only for the prevention of 
phthisis, but also for the cure of insanity, it should be impossible 
for any patient to complain justly that he cannot get enough food. 

It is imperative that phthisis be recognized as early as possible. 
Whenever a patient suffers from cough or is seen to be in ill- 
health, his temperature must be taken regularly every night for 
a few weeks, his weight taken every week in order to discover 
whether he is losing flesh and his chest carefully examined from 
time to time. Wasting of the upper part of one trapezius 
muscle is an early sign; in looking for this the doctor should 
stand behind the patient. One mode of investigation is to 
obtain a small pipetteful of blood and to estimate the opsonic 
index. V. Pirquet’s reaction with pure tuberculin is a rather 
more reliable test. As a rule, tubercle bacilli cannot be dis- 
covered in the sputum from early cases. 

Lastly, phthisical patients are to be isolated from the non- 
infected and to receive treatment. At present no sanatorium 
exists for the phthisical insane; but some establishments have 
now instituted an arrangement whereby their phthisical patients 
can live entirely in the open air. Beds can be placed under a 


524 MIND AND ITS DISORDERS 


shelter against a wall facing south, somewhat like a cloister. 
The patients can remain in bed the greater part of the day and 
receive an allowance of 3 or 4 pints of fresh milk in addition to 
their ordinary food. 

For further details of the diagnosis and treatment of phthisis — 
the reader is referred to textbooks on general medicine. 


ASYLUM DYSENTERY. © 


This disease, which was long known under the name of “ ulcera- 
tive colitis’’, is now considered to be the bacillary dysentery 
familiar to dwellers in the tropics and is ascribed to infection 
by a modified Bacillus dysentert.e of Shiga. 

Outside the asylum population dysentery is a rare disease 
in this country. Unfortunately it is deplorably common in 
asylums. In 1911, 1,203 of 99,742 inmates of county and borough 
asylums were reported to the Commissioners as suffering from 
dysentery. Of these, g12 recovered and 240 died, 51 remaining 
under treatment at the close of the year; and this in spite of 
the fact that sixteen of the ninety-five asylums were reported 
free from dysentery. There is not the slightest doubt that 
the true condition of affairs is very much understated by these 
figures. On the one hand, Dr. Mott tells us that the disease 
sometimes exists without giving rise to characteristic symptoms 
and is not discovered until the case reaches the post-mortem 
table; on the other hand, many superintendents are unwilling 
to report dysentery as a cause of death and thus to proclaim their 
particular asylum to be insanitary when other possible causes of 
death can be discovered. 

Etiology.—As already stated, the disease is infectious. Evidence 
goes to show that it is communicated to the healthy by means 
of the evacuations from the sick, as in typhoid. When once 
dysentery is introduced into an asylum, even of the most modern 
and hygienic type, it is extremely difficult to drive it out again. 
The same remark applies to individual wards and even indi- 
vidual beds of an institution. Still more is it applicable to 
individual patients for, according to Dr. Mott’s report, active 
lesions may be found post mortem in the colon of a patient 
who has been free from all symptoms of the disease for years. 
Hence it is liable to be spread through the injudicious transfer 
of cases from one ward to another or, worse, from one asylum 
to another. In so far as transfers are frequently necessitated 
by the overcrowded state of our asylums, overcrowding is to 
be regarded as a contributory cause of the disease. 


Assy LUM DYSENTERY 525 


Perhaps the most important causes of its relative frequency 
in asylums are the filthy habits of many of the patients them- 
selves, in regard to which it is unfortunate that asylum nurses do 
not, as a rule, receive sufficient instruction concerning the nature 
of infection and the mode of disinfection of contaminated articles. 

As is well known, the disease is not limited to the insane, even 
in asylums. Experience has proved that medical officers and 
nurses are just as lable to infection. 

Incidentally it may be mentioned that dysenteric lesions are 
found post mortem twice as frequently in females as in males 
and that alcoholics appear to be more liable to the disease than 
other patients. 

Symptomatology.—Asylum dysentery usually sets in with rise 
of temperature (101° to 103° F.) and a rigor. Within the next 
two days there are colicky pains followed by persistent diarrhoea 
which may be accompanied by tenesmus. 

On examination the abdomen is found to be moderately dis- 
tended and tender, especially in the hypogastrium. The tongue 
may be either unduly red and dry or coated with a white or 
brown fur. The pulse is small and frequent. 

The evacuations are loose; their odour is offensive and so 
characteristic that the medical officers of institutions where the 
disease is rife can recognize a case from the odour alone. The 
stools contain blood and slime to a variable extent, the slime 
consisting almost exclusively, according to Sir Frederick Mott, 
of polymorphonuclear leucocytes and mucin, with a few decay- 
ing columnar cells. 

Sir Frederick recognizes seven different clinical types of asylum 

dysentery : 
“yy, The acute case, with preliminary fever, lasting till death 
supervenes in about two to ten days. 

“2. The acute case, with preliminary fever, and a temperature 
which falls rapidly as the collapse proceeds. 

‘3. The case with mild fever, 101° to 103° F., and diarrhcea for 
a day or two, accompanied by diarrhoea with blood and slime 
in the stools for a few days to a week or more; terminating, 
however, in recovery. 

“4. The mild case without fever, but with diarrhoea, accom- 
panied with blood and slime, lasting over two days. In some of 
these cases there may have been initial fever, which was overlooked. 

‘5. Cases of varying degrees of severity in which, after an 
interval of a few days, symptoms recur, sometimes with fatal 
results and sometimes with recovery. 


526 MIND AND ITS DISORDERS 


“6. Cases which do not clear up after the first week or two, 
but which become chronic: the patients continuing at more or 
less intermittent intervals to pass bloody, slimy, diarrhceal 
evacuations for months. Such are common.” 

“7. Cases of intermittent or prolonged diarrhoea, in which 
neither blood nor slime has been noticed in the stools, and yet 
post-mortem dysenteric lesions of a similar nature have been — 
found.” 7 

Sir Frederick Mott further draws attention to the fact that 
asylum dysentery may coexist with phthisis and may then be 
mistaken for the diarrhoea of the latter disease. 

Morbid Anatomy.—The mucous and submucous coats of the 
large intestine are red and swollen and the mucous coat is firmly 
adherent to the underlying tissues, so that it cannot be moved 
on them. The whole colon may be the seat of all shapes and 
varieties of ulcer, varying in size from the most minute up to 
several inches in length and breadth. Primarily they are cir- 
cular, but by coalescing they may acquire a serpiginous outline. 
Hemorrhagic points, black or grey sloughs and healing edges 
may be seen here and there, according to the acuteness and 
intensity of the disease. 

Treatment.—In the interest of the non-infected it is of prime 
importance that all cases of dysentcry be isolated in a separate 
building from other patients. Clothing, bedding and _ utensils 
should be disinfected as carefully as if the patients were suffering 
from scarlet fever or diphtheria. The nurses must be made to 
understand that they are dealing with cases of an infectious 
disease and they should be instructed in the general principles 
and methods of preventing the spread of such diseases. Special 
care is to be taken to disinfect at least the nozzles of enema 
syringes used for these cases. 

The treatment of patients suffering from the disease consists 
of disinfection of the large intestine and prevention of collapse. 
The former may be effected by the administration of salol, 
6-naphthol or salicylate of bismuth by the mouth and by lavage 
of the large intestine by copious enemata of lukewarm water 
to which a small quantity of some non-irritating antiseptic, such 
as creasote or lysol, may be added. If the diarrhoea be not 
excessive, magnesium sulphate may be regularly given by the 
mouth to assist in the elimination of toxic products. 

For the mitigation of an exhausting diarrhcea, brandy, almost 
neat, should be given in 1-ounce doses by the mouth and starch- 
and-opium enemata administered per rectum, 


CUTANEOUS AFFECTIONS 527 


The patient is of course to be kept at rest in bed and to use 
the bed-pan. To be orthodox the diet should be liquid and 
highly nutritious but non-irritating and of small bulk. These 
qualities are to be found in milk, given with barley-water, and 
good meat-essences, the latter being neither hot nor cold, but 
warmed to a temperature of about go° F. But I know of a 
medical man who cured himself of dysentery of four years’ 
standing by taking porridge every morning and returning to an 
ordinary diet. 

A serum has been prepared by immunizing horses for the 
bacillus of Shiga and this has had much success in treatment 
of the disease. It should be given in doses of 20 c.c. two or 
three times a day. I believe it can be obtained from the Lister 
Institute. 


CUTANEOUS AFFECTIONS. 


It is a matter of common observation that the skin of most 
patients suffering from mental disease is unhealthy and sallow. 
In many cases it emits an unpleasant characteristic odour which 
I believe to be of bad prognostic significance; and there are 
certain cutaneous disorders which occur more fréquently among 
the insane than among the sane. This association between 
cutaneous and nervous diseases might very well be expected in 
view of the common origin of the cutaneous and nervous systems 
from the epiblastic layer of the embryo and in view of our 
experience that those drugs which have medicinal or toxic 
influence on the skin are to a large extent identical with those 
which have a similar influence on the nervous system. 

The insane are, of course, liable to the same skin affections as 
other people. There are also certain of these affections to which 
they are especially subject. These are seborrhcea and acne, 
erythrasma, hypertrichosis, anomalies of pigmentation, so-called 
“insane fingers ’’ and adenoma sebaceum. 

Seborrheea is common enough among the sane, but it is rela- 
tively more frequent and more severe among the insane. Most 
commonly it affects the scalp, where it causes dandruff and 
thinning of the hair. The disease sometimes goes farther than 
this and gives rise to inflammation of the scalp (seborrhceic 
dermatitis or eczema capitis). There is no danger in the disease, 
except to the patient’s personal appearance, but it is desirable 
that the senior members of the nursing staff should be instructed 
as to its nature; otherwise they may blame their juniors for the 


528 MIND AND ITS DISORDERS 


dirty condition of a patient’s head, whereas no amount of brush- 
ing per se will get rid of dandruff. 

Next to the scalp the most common site for seborrhcea is just 
above the ale nasi where little pellets of sebum may often be 
seen to have accumulated on insane patients. 

Acne Vulgaris, which is really the same disease as séboroam | 
affecting the face, chest and back, is extremely common among 
insane adolescents. It is too well known to require deserineae 
in a book of this nature. 

Tveatment.—In the treatment of these conditions it is essential 
to begin with the scalp. When the hair is full of dandruff it is 
useless to attempt to cure acne. Seborrhcea may be cured as 
follows: Wash the head nightly with soap-spirit (soft-soap 
2 parts, rectified spirit 1 part) or Packer’s pine-tar soap, wash 
all the soap out of the hair with plenty of clean water, then apply 
to the scalp (the hair will take care of itself) with a piece of 
sponge, a strong solution of perchloride of mercury (I in 250). 
This is not too strong for most cases: the scalp will quite com- 
monly tolerate a I per cent. solution. If the sebum be collected 
in crusts on the scalp or if there be any dermatitis, it is better to 
use the following ointment: 


Precipitated sulphur fs 
é : : of each 
Salicylic acid - : 

: 10 grains. 
Resorcin : rY aoF Bie 
Vaseline os Ay is ie I ounce. 


This ointment is useful also in treating seborrhcea above the ale 
nasi, after the pellets of sebum have been scraped away with 
the finger-nail. 

Erythrasma.—This is a disease of little importance, apparently 
allied to pityriasis versicolor. I have never seen it in the sane, 
among whom it is said to be very rare; but I have seen at least 
a dozen cases among the insane, among whom it sometimes 
occurs in mildly epidemic form in asylums. Erythrasma usually 
makes its appearance in the neighbourhood of the genitalia in 
the form of reddish-brown spots which spread peripherally and 
clear up pari passu in the centre, thus forming reddish-brown 
rings. These rings coalesce and give the rash a marginate or 
circinate appearance; indeed, the disease has been called by 
some authors “‘ eczema marginatum ”’ 

Treatment.—Erythrasma is due to a fungus, the Mzicrosporon 
minutissimum, of feeble vitality. It is therefore easily cured 
by a few vigorous applications of a solution of perchloride of 
mercury (I in 1,000) or of hyposulphite of soda (x in 8), the 


CUTANEOUS AFFECTIONS 529 


skin being previously washed with plenty of soap and warm 
water. 

Hypertrichosis.— Reference has already been made to this 
condition in the chapter on the physical stigmata of degeneration. 
Many women suffering from mental disorder, especially of the 
more chronic varieties, develop bristly hair about the face. In 
some cases the growth is sufficiently profuse to attain the dignity 
of a beard and moustache. This is a very real affliction to a 
sensitive woman and her comfort will be greatly promoted if it 
is removed. It is not generally known that this can easily be 
done without the use of a razor, by dissolving the hair in a 
solution of sulphide of barium or calcium. The best way of 
doing this is to make a paste, with water, of equal parts of oxide 
of zinc, starch, sulphide of barium and sulphide of calcium. 
This is spread over the affected part, left for ten minutes and 
then washed off, the dissolved hair coming with it. The paste 
should always be freshly made. The slight irritation caused 
by it may be relieved by the application of a little powder. 

A bristly growth of hair on the face is, of course, characteristic 
of masculinity, and its common occurrence in the female insane 
has definite relationship with the frequency of repressed homo- 
sexuality as a common psychological basis of insanity. 

Pigmentary Disturbances.—Vitiligo or leucoderma (piebald 
skin) has already been mentioned as one of the stigmata. Other 
anomalies of pigmentation sometimes occur, apparently as a 
concomitant of mental disorder. On several occasions I have 
thought that the complexion of a patient has become much 
darker during twelve months’ residence at Bethlem, but it is 
difficult to be sure; it is no easy matter to recall the former 
colouring of a patient whom one has seen almost daily for twelve 
months on end. None of the patients in whom I have suspected 
this change of complexion recovered from the mental disorder. 
Dr. Hyslop has reminded us of the case, recorded by Laycock, of 
“a woman who, during the French Revolution, incurred the anger 
of the Parisian mob and with difficulty escaped being hanged in 
the streets. Her terror caused a gradual black discoloration of 
the whole body, and this remained with her until her death, 
thirty-five years afterwards ”’ 

The name insane fingers has been applied to a low form of 
whitlow to which the insane, especially general paralytics, are 
liable. The condition appears to be less common than formerly, 
probably on account of improved hygienic surroundings and 


greater cleanliness on the part of the attendants. 
: fs 


530 MIND AND ITS DISORDERS 


Pellagra.— Until a few years ago it was believed that pellagra 
was unknown in this country; but several cases have now been 
described, especially in asylums. It is endemic in Northern Italy 
and other countries in that region and in the United States of 
America, and its incidence used to be ascribed to eating bread 
made from diseased maize, but it has more recently been held that 
the disease is an infection. It is not communicable from person 
to person, but Dr. Sambon has suggested that it is a protozoal 
disease caused by the bites of infected insects, especially certain 
flies of the genus Simulium. The disease affects the skin, nervous 
system and intestinal tract. The skin affection shows itself during 
the hot months of the year, when those parts exposed to the 
rays of the sun (face, arms and sometimes feet) become first 
congested, then pigmented and thickened. Desquamation takes 
place during the later months. These processes occur for four or 
five successive years; ultimately the skin becomes dry, wrinkled 
and atrophied. 

At the same time cerebral degeneration takes place in many 
of the patients. They suffer from attacks of mental depression 
or, less commonly, excitement or stupor. There is also degenera- 
tion of the lateral and postero-median columns of the spinal 
cord, giving rise to the clinical picture of postero-lateral sclerosis. 
Certain associated gastric disturbances have been ascertained by 
Agostini to be due to hypopepsia. In fully developed cases the 
disease is almost invariably fatal. 

Adenoma Sebaceum.—Patients suffering from this disorder 
are almost invariably of feeble intellect and the majority are 
to be found in institutions for imbeciles. The patients are 
usually subject to epileptic fits. We would also gather from a 
paper by Dr. Sherlock, now Superintendent of the Darenth 
Industrial Colony for Mental Defectives, that the condition is 
usually, if not always, associated with patches of tuberose 
sclerosis in the cerebral cortex and basal nuclei and with adeno- 
matous growths in the kidney which give rise to no clinical 
symptoms during life. With remarkable economy of con- 
sonants, Dr. Sherlock originally named this disease or symptom- 
complex “anoia’’, but he has now rechristened it “ epiloia ”’ 
These patients all die young; the average age at death in Dr. 
Sherlock’s series of twelve cases was thirteen years and ten 
months. 

Adenoma sebaceum is limited to the face and occurs mostly 
on the nose, cheeks and chin. It consists of yellowish-white 
waxy-looking papules not larger than a mustard-seed, which are 


CUTANEOUS AFFECTIONS sient 


covered and surrounded by small telangiectases, giving the face 
a mottled appearance. 

Lichen Planus has rather a different relationship. That the 
disease is sometimes or possibly always of “nervous” origin is 
well recognized by dermatologists. A patient suffering from 
this malady was introduced to me by a leading dermatologist 
and is now being psycho-analyzed. The progress is slow, but 
she has gone far enough to convince me that—in her case— 
the lichen planus is undoubtedly psychogenetic. For obvious 
reasons I can give no details, but the eruption is the fulfilment 
of an unconscious wish to have a (syphilitic) rash and she can 
now, in some subconscious way, prevent the appearance of a 
papule although the prodromal itching has already occurred. 

Evans and Jelliffe have reported a case of Psoriasis in which 
psycho-analysis disclosed it to be of hysterical origin. We may 
therefore infer that at least some other cases may be psycho- 
genetic—perhaps all. At any rate, as with lichen planus, we 
can say that no pathology of psoriasis has been advanced which 
is more satisfactory. 

Urticaria is another skin disease whose existence has not yet 
been sufficiently explained. It is commonly caused by articles 
of diet, such as crabs, lobsters and strawberries, which have 
hence acquired the reputation of being indigestible; but they 
are not really indigestible. Most people can digest them per- 
fectly well and chemically their difference from other foods is 
trifling. On the other hand, such articles of diet are just those 
which are commonly recognized by psycho-analysts to have an 
unconscious symbolic meaning to some patients. It seems 
probable, therefore, that urticaria may ultimately have to be 
classed as a neurosis. 


CHAPTER XXVIL. 
CASE-TAKING. 


In all cases of illness it is advisable to obtain some history of 
the patient before proceeding to examine him, but in cases of 
mental disorder this must usually be obtained from the friends 
since the statements of patients are liable to be erroneous. 

Probably the best way to take the history of an existing illness 
is to ask for the first symptom that led the friends to think that 
there was anything wrong with the patient and to get a detailed 
history of this symptom up to date. Then ask what was the 
second symptom noticed and obtain a detailed history of this 
up to date, and so on with the third, fourth and subsequent 
symptoms. The friends should be asked when the patient left 
work, and why. Finally, discrepancies and fallacies should be 
pointed out and gaps filled up. It is also well to ask for sup- 
posed predisposing and exciting causes with the evidence of 
etiological relationship. 

An account should then be obtained of the patient’s ordinary 
health, of the regularity of the bowels and catamenia, of previous 
attacks of similar or allied diseases, of previous illnesses of other 
kinds and especially of venereal disease. In the case of women, 
evidence of the last is usually to be obtained indirectly by 
inquiries respecting skin eruptions, falling of the hair and mis- 
carriages. 

The patient’s previous habits should be investigated with 
respect to food, alcohol, idiosyncrasies and any special liability 
to business or domestic worries. 

In obtaining the family history the medical man should ask 
about the age and general health of the parents, grandparents, 
brothers, sisters and children and find out whether there has 
been any other mental or nervous disease in the family. 

Psycho-analytic experience has taught us to pay rather less 
regard to the general family history and to inquire more especi- 
ally respecting mental peculiarities of the parents themselves or 
their surrogates; for we now know that these have an enormous 
influence upon the child during his earlier years, at least as great 
as and probably greater than heredity, in laying the foundation 

532 


EXAMINATION OF PATIENTS 5353 


of his subsequent character if he remains healthy, or of his 
neurosis or psychosis when he does not. 

The examination of patients suffering from mental disorder 
cannot be carried out in a routine manner as in the case of those 
suffering from other diseases. With the former greater patience 
is required and allowances must be made for caprices and whims. 
Until fairly recently it used to be the rule for the physician to 
direct the course of the conversation to the best of his ability, 
the patient being allowed to have his say; but nowadays, if time 
permits, we find that we get a far better grasp of the patient’s 
mentation by allowing him to do all the talking from the very 
beginning. At times, however, this is impracticable. Even then 
one cannot, therefore, lay down hard-and-fast rules as to the 
order in which the various mental faculties are to be examined. 
Further, the doctor will find it necessary to vary his mode of 
examination in accordance with the kind of patient with which 
he finds himself confronted. It is hoped, however, that the 
following may serve as a useful framework on which to base the 
scheme of examination. It will be seen that, in the first instance, 
this partakes, more or less, of the nature of an ordinary con- 
versation. 

Greeting: 

“Good-morning !”” Offer the hand, and notice whether the 
patient’s handshake is of the maniacal, melancholiac or praecox 
variety. If he refuses to shake hands, endeavour to find the 
reason for his refusal. 

Ask his name, age, civil state and occupation. With the object 
of making a preliminary test of his memory and of ascertaining 
the length of his illness, ask him when he was last engaged at 
his usual occupation. 

‘How are you?”. (In an institution) ““ Why have you been 
brought here ?”’. (In private) ‘“‘ Why have I been called to see 
you ?”. The answer to these questions will reveal iter alia 
whether the patient has any insight into the nature of his illness 
and, ipso facto, whether he has any delusions. 

Orientation in space: 

‘Where do you live ?”’. ‘‘ Do you know what place this is ?”’. 
‘Where is it situated 2”. ‘‘ How far is it from your home ?”. 
““ By what route did you come here ?”’. 

Orientation in time: 

“How long have you been here ?”’. “‘ What is the day of the 
week ?”. ‘Of the month 2”. ‘ What month is it ?”’. ‘“ What 
year ?’”’. ‘‘Whatcentury?’’. “‘ What time do you think it is ?”’. 


534 MIND AND ITS DISORDERS 


Associative memory : 

“Who brought you here?’”’. “When did you arrive ?”. 
“What were you doing a week ago?’’. “A month ago?”. 
Here the patient should be asked to give an account of his illness 
and to explain or refute the statements in his certificates, if there 


are any. 
Recognition: 
““ Have you ever been here before ?’’. “‘ Do you know who I 
am ?’’. ‘“‘ Do you know any of these people present ?”’. 
Perception: 


“What sort of a place do you think this is? Is it a theatre ? 
club ? hospital ? hotel ?”’. 

For the purpose of further testing simple perception the 
physician should carry a few articles in his pocket, such as a 
fountain-pen, a pencil-holder, a matchbox and a button-hook 
as well as a few unfamiliar objects to serve as more severe tests 
such as a pocket stamp-case, a tape-measure, a tie-clip, a retino- 
scope and a pocket electric-lamp. The author usually carries 
a small letter-opener with a large lens set in one end of it and 
uses it for this purpose. The patient is required to name such 
objects and to say what each is for. The same articles may be 
used to examine for apraxia by asking the patient to show how 
he would use them. Picture-books, especially children’s picture- 
books, are also useful. Customarily the author uses two of 
these: one, Dean’s rag “‘ Baby’s Object Book ”’, gives pictures and 
names of common objects and serves as a mild test for severe 
cases; the other, ‘“‘ Proverbs Old Newly Told”’, published by 
Raphael Tuck and Sons, has pictures which portray proverbs and 
serve as a severe test for mild cases. In practice, the letter- 
press is covered up and the patient is required to identify the 
object or proverb, as the case may be. It is advisable occasion- 
ally to try normal people with these to make sure that the test is 
not too severe. 

Ideation or the revival of memory images is perhaps best tested 
by asking the patient to enumerate a dozen birds, a dozen fishes 
or a dozen flowers. In severe cases the physician will do well 
to choose objects with which the patient is very familiar; while, 
to test the progress of a convalescent patient, he will ask for 
something more difficult, e.g., a dozen people whom one sees in 
uniform in the street. 

Auditory perception is tested by asking the patient to recognize 
some familiar sound made behind his back, such as the rattle of 
keys, the tearing of paper or the spurt of a soda-water siphon. 


EXAMINATION OF PATIENTS 535 


Auditory word-perception is tested by giving some simple com- 
mand in a monotone and without gesture, e.g., “‘ Put your left 
hand on your right shoulder ” (of course, without gesture by the 
physician), or, as a slightly more severe test, asking some question 
more or less complex, such as “ Would you prefer a brown coin 
or a yellow one ?”’. 

Taste and smell perceptions may be examined with a series 
of test solutions such as, for the former, dilute solutions of salt, 
sugar, quinine and citric acid, and for the latter, oil of cloves, 
oil of peppermint, tincture of asafcetida and essence of lavender. 
Cutaneous anesthesia may be examined and charted at this 
stage. 

It is while these tests are being carried out that it is best for 
the physician to inquire for hallucinations: 

“ Are you ever troubled by light or visions of any kind, such 
as faces appearing before the eyes, especially at night when your 
room is dark ?’’. “‘ Do they occur during sleep or when you are 
awake ?’’, 

“ Do you suffer from noises in the ears ?”’. “‘ Do you ever hear 
sounds which seem like people talking, especially during the 
silence of the night when there is nobody present ?’’. ‘‘ Do you 
recognize the voices ?’’. ‘‘ What do they say ?”’. 

“Do you experience unpleasant or otherwise strange and un- 
accountable sensations of taste ?’’. “‘ Or of smell ?”’. “Do you 
often think that there is something burning or that the drains are 
defective, when other people say that they smell nothing of the 
kind ?’’. “‘ Have you any pain or discomfort anywhere ?”’. 

Delusions: 

“ How do you account for these visions, voices, odours and 
other sensations ?”’. ‘“‘ Do you realize that they are the outcome 
of your present nervous condition ?”’. ‘‘ Do you think there is 
anybody who wishes to do you any harm, who exercises any occult 
influence over you or reads your thoughts ?’’. “‘ Do you suffer 
from a feeling that something dreadful is going to happen ?”’. 
“Are you particularly worried over religious matters ?”’. “* Do 
you sometimes feel that you have led a wicked life? And that 
your soul is lost ?”’.  ‘‘ Are your financial affairs sound ?”’. 

Attention, perception and memory may also be tested by 
telling the patient a short anecdote and getting him to repeat 
it. These can be selected in various degrees of complexity. 
Here are two extremes which I commonly employ: 

(x) One Jew said to another, ‘‘ Have you taken a bath ?” and 
he replied ‘“‘No! Have you lost one ?”’. 


536 MIND AND ITS DISORDERS 


(2) A Scotchman named Thompson who had been out of work 
in Glasgow for a considerable time at last obtained some employ- 
ment at the docks. On being asked his name by the foreman, he 
replied ‘“‘ Tamson ”’ (as it is pronounced in Glasgow). He set to 
work on his job, which turned out to be exceedingly heavy, for 
he had to move great barrels of tar as high as himself. So he 
returned to the foreman after about a quarter of an hour, and 
asked if he had taken his name correctly. The foreman told 
him that he had understood his name to be ““ Tamson’’. “‘ Aye,”’ 
said the man, “‘ that’s a’ richt, I thocht ye micht ha’ pit doon 
‘Samson ’ by mistake ’’. 

During this examination the doctor will have noticed peculi- 
arities about the patient’s general attitude and behaviour. He 
will have ascertained whether the prevailing affective tone is 
one of depression or exaltation; and he may also test emotional 
reaction by showing the patient a comic picture and observing 
whether he laughs or not. Further inquiries may now be made 
of the nurses or relations concerning his habits. 

The medical man may now proceed to ask the patient about 
his physical health as in an ordinary medical case, endeavouring 
to elucidate symptoms of disorders of the circulatory, respira- 
tory, digestive and other systems and, incidentally, he will note 
whether he appears to be suffering from hypochondriacal delu- 
sions or has distorted views of the nature of his illness. 

Then follows the ordinary systematic physical examination. 
Note the general aspect and complexion, the colour of the skin 
and mucous membranes, the presence or absence of wounds, 
bruises, bedsores, scars and skin eruptions. 

Observe the facial expression and note physical stigmata and 
other obvious deformities. 

Examine the general nutrition, note signs of wasting and have 
the weight and temperature taken. Observe whether the ex- 
tremities are cold, cyanosed or cedematous. Note the frequency 
and other characters of the pulse and respiration. Look at the 
tongue and see whether it is tremulous, tooth-indented, furred, 
coated or plastered, white or brown, dry or moist. 

Make an examination of the chest and abdomen and test the 
urine. 

If the patient suffers from headache, make inquiries as to its 
position, characters and associations. Find out during which 
part of the night he sleeps and for how many hours. 

If he suffers from fits, get a description of them. Is there any 
assignable cause for them ? When did they begin ? What were 


EXAMINATION OF PATIENTS 557 


the longest and shortest intervals between them and when did 
those occur? Is there any aura? Ifso, how long after the aura 
does the convulsion begin? Is the onset sudden or gradual ? 
Does the patient scream at the onset or during the fit ? Does he 
bite his own tongue or other people or things ? Does micturition 
or defecation take place? Is restraint necessary ? If so, is it 
to prevent accident or violence ? What is the duration of a fit ? 
Is the termination spontaneous or induced ? What symptoms 
occur afterwards—sleep, headache, or automatism ? 

If the medical man has an opportunity of observing a fit, 
he should note the order of convulsion of various parts of the 
body and limbs, the colour of the face, the conjunctival and 
pupillary reflexes, the response to a pinprick and the mobility 
or immobility of the chest. He should also examine the knee- 
jerks during, immediately after and some time after the con- 
vulsion. 

In the physical examination of the nervous system, special 
attention should be devoted to the eyes. The vision should be 
tested and errors of refraction recorded. Are the visual fields 
contracted? Are there any positive or negative scotomata ? 
Examine the fundus oculi with the ophthalmoscope and note 
especially whether there is any swelling of the optic disc. Test 
the movements of the eyes and note whether there is any nys- 
tagmus. Note the size and outline of the pupils, their reaction 
to light and the consensual and sympathetic reflexes. Do they 
contract on convergence ° 

Is there any defect of hearing as tested by the tick of a watch ? 

Are the muscles or nerves of the limbs tender to pressure ? 

Observe the position of the trunk, head and limbs while at rest. 
Test whether there is any rigidity of these and whether there 
are any abnormal movements, such as tremor. Tremor, other- 
wise unobserved, may often be noticed in the fingers by getting 
the patient to hold out his hands, dorsum upwards, with the 
wrists extended and the fingers widely separated. Examine for 
flexibilitas cerea and echopraxia and note signs of negativism. 

Test the superficial reflexes, especially the epigastric, cremas- 
teric and plantar. Examine the tendon reflexes, especially the 
knee-jerk. Test for rectus clonus and ankle clonus. Note dis- 
turbances of organic reflexes—deglutition, appetite, vomiting, 
defecation and micturition. If there is incontinence, determine 
by passing a catheter whether it is reflex or overflow. 

Note vasomotor and trophic changes and observe whether 
perspiration is excessive or deficient. 


538 MIND AND ITS DISORDERS 


Observe the gait. 

In examining the articulation, get the patient to repeat some 
of the usual test phrases: British Constitution, Irish artillery, 
Biblical commentators etc. 

Is speech excessive or deficient? Is it coherent? Is it 
abusive and does the patient use coarse language ? Can he read 
correctly ? Can he sing a song with the words ? Note verbigera- 
tion, echolalia and pseudolalia. | 

Lastly, obtain a specimen of the patient’s writing and study it 
carefully; for the whole of a patient’s thought and action are 
reflected in his writing. 

It is frequently helpful, too, to get him to make some simple 
arithmetical calculation on paper, e.g., to multiply 345 by 67. 

The scheme given here is intended to serve merely as a basis 
for further investigation by methods suggested to the examiner 
by the patient’s answers. Those readers who require a more 
detailed method of mental investigation will find it in Franz’s 
‘Handbook of Mental Examination Methods” (Nervous and 
Mental Disease Monograph Series, No. 10). 


CHAPTER XXVIII. 
GENERAL TREATMENT. 


OuR general survey of the nature of mental disease has taught 
us that it may be due, on the one hand, to such physical calamities 
as gross lesions or toxic influences upon the general nervous 
system, local or general metabolic changes etc., or, on the other, 
to purely intrapsychic mechanisms. The specific methods for 
dealing with the former have already been touched upon in 
appropriate places during the earlier chapters of this work. 
The latter include the neuroses and biogenetic psychoses. Of 
these, the neuroses are almost invariably amenable to some form 
of psychotherapy, as also are some of the milder forms of the 
psychoses. These may be treated in the consulting-room, in the 
mental out-patient departments of general hospitals or at the 
patient’s own house; but in quite a large number of psychotic 
patients the gross disturbance of the patient’s conduct and other 
considerations raise the question whether, nay, imperiously 
demand that, the patient ought to be transferred to some forin 
of mental hospital for care and treatment. 

When this state of affairs arises the first thing to be deter- 
mined is the place where he is to be taken care of and treated. 
Except in the case of old people to whom the sudden change 
from home to institution life is likely to prove irksome and 
detrimental, there is not the slightest doubt that mental patients 
are best off in an institution especially built or adapted for their 
requirements, under the care of skilled nurses especially trained 
in the management of the insane and under the supervision of 
medical men who have had a large experience of mental disorders 
and have made them their special study. Owing, however, to 
the way in which an ignorant public regards a person who has once 
been under care in an asylum as somewhat of the nature of a freak 
and stigmatizes him with such kakophemisms, if I may coin 
a word, as ‘‘madman”’ and “ lunatic’’, the friends of the patient 
are often anxious that the treatment should, if possible, be carried 
out in a private house. The possibility of this course depends 
partly on the nature of the disease and partly on the funds 

539 


540 MIND AND ITS DISORDERS 


available for the purpose, treatment in a private house being 
an expensive procedure. Symptoms which render asylum care 
imperative in 99 per cent. of cases are homicidal and extremely 
suicidal tendencies, great excitement with noisiness, persistent | 
refusal of food and dirty habits. 

When it is decided to carry out the treatment ina private house, 
it is necessary to engage at least two nurses and sometimes, 
according to the nature of the case, four or even six, who should 
of course be selected on account of their having had abundant 
previous experience of mental disorder, will consequently make 
due allowance for the patient’s symptoms and not treat them 
as inexperienced people do, as if they were a manifestation of 
innate wickedness. 

A suite of rooms, preferably on the ground floor, should be set 
apart for the patient and his nurses and adapted so as to minimize 
the risks attendant on the home treatment of mental disorder. 
The nurses should have charge of the keys, stops should be placed 
in the frames of the windows, a guard fixed round the fire, the 
bolt removed from the door of the water-closet, and such orna- 
ments and projections as the patient might use for self-injury 
taken away. These precautions having been carried out the treat- 
ment is otherwise much the same as in institutions for the insane. 

Contraband of Lunaey.—All sharp-pointed and cutting instru- 
ments such as knives, razors and scissors must be locked up 
and all keys taken away. Experience teaches that Bibles and 
Prayer-Books are usually a source of worry to a mind diseased, 
instead of the comfort they should be. The physician will do 
well to consider in each individual case, after an examination of 
the patient, whether it will not be wise to make these books also 
contraband. If it, be decided to forbid the use of Bibles and 
Prayer-Books, the patient will also, of course, not be allowed to 
attend church. 

Chess is too severe a game for a person whose brain requires 
rest and I recommend that sets of chessmen be forbidden to any 
person suffering from acute mental disorder. 

Flannelette night garments are to be disallowed for the reason 
that flannelette is too inflammable, can be torn noiselessly under 
the bedclothes and a strip of it used for suicidal purposes. 

Bed.—It is best to commence the treatment of all cases of 
insanity by a few days’ rest in bed. In chronic cases this gives 
the physician an opportunity of making a complete mental and 
physical examination of the patient and allows the nurses time 
to make observations. In acute cases bed forms an important 


THE PHYSICIAN’S BEHAVIOUR TOWARDS THE PATIENT SAT 


item in the treatment. The value of bed-treatment has already 
been insisted upon under the headings of the various diseases for 
which it is desirable. It should be remembered, however, that 
the habit of masturbation contra-indicates prolonged rest in bed 
and that neurasthenics easily contract the ‘“ bed habit ”’. 

The Physician’s Behaviour towards the Patient.—It should 
always be borne in mind that nearly all patients suffering from 
acute mental disorder are abnormally sensitive. Therefore, if 
for no other reason, be kind to them and studiously avoid hurting 
their feelings. Remember that ill-humour may be a symptom 
of their disease and require treatment as such. Never allow 
yourself to feel irritated by patients. 

Most patients are aware that they require a strong, robust- 
minded friend who thoroughly understands their weakness, on 
whom they can rely for moral support and comfort and in whom 
they can place implicit confidence; whether they know it or not, 
the fact is so. The person who should occupy this position in 
the patient’s mind is his physician. The latter should therefore 
never deceive a patient. From the moment of his entry into 
the institution, be frank with him. It often happens that a 
patient is enticed into an establishment by means of some little 
fraudulent device; he is, for example, told that the place is 
an hotel and his physician is requested not to disillusion him; 
but to do this would be to lose his confidence for ever. His 
position should at once be frankly explained to him and sub- 
sequent experience of his doctor be such as to teach him that he 
is dealing with a straightforward man. Further, the doctor’s 
examination must be thorough and of such a nature as to tell 
him all about his patient and to let the patient see that he © 
knows all about him. Be interested in his conversation and 
sympathetic, let the tale of woe be never so familiar. By such 
means confidence will be won. 

Lastly, be serious but cheerful. Moods are contagious and 
words of comfort and encouragement are more readily accepted 
by a patient if he is in a serious but cheerful mood. Suggestion 
as to recovery is carried out by pointing out amelioration of 
symptoms. Delusions should be listened to but not discussed, 
it is foolish to argue with a patient about subjects in regard to 
which his judgment is disordered. Probably the best attitude 
to take up with regard to delusions is to let the patient know 
that you are trying to see matters from his point of view but, 
when an appropriate occasion arises and not one minute before, 
to drop a hint that he may be mistaken. 


542 MIND AND ITS DISORDERS 


Occupation.—This is good for patients, provided it is not of 
such a nature as to require strenuous physical exertion or mental 
strain. At Bethlem Hospital many patients were at one time 
taught to make baskets and wool rugs, mild occupations which do 


not interfere with rest in bed. Sewing, knitting and the reading © | 


of light literature are also permissible for acute cases. For 
chronic patients who are capable of employment, regular daily 
work is not only permissible but directly beneficial. In county 
and borough asylums much useful work is done which serves to 
keep down the rates. 

Seclusion and Mechanical Restraint.—When a patient cannot 
by persuasion be induced to remain in his room and to take his 
rest, restraint becomes necessary. This may be accomplished 
(1) by locking the door of his room (seclusion), (2) by a number 
of nurses holding him or (3) by the administration of powerful 
drugs such as hyoscine. Of these the last may be directly in- 
jurious to the nervous system and is to be regarded as a refined 
substitute for hitting the patient on the head with a club; the 
second involves a resistant struggle on the part of the patient, 
with consequent exhaustion; while the first involves nothing 
more serious than keeping a record of the number of occasions 
and number of hours during which the patient is secluded and 
reporting the same to the Board of Control every three months. 

There can be no doubt that seclusion is the least harmful 
method of restraint. Out of common humanity it should be 
resorted to as little as possible, for it is naturally somewhat irri- 
tating to a patient to be locked in his room; but it is the least 
of the three evils. 

Mechanical restraint may be employed to hamper certain move- 
ments of the body for surgical reasons or in order to prevent self- 
injury or injury to others. The commonest form of mechanical 
restraint and probably the only necessary form, apart from 
splints for fractures etc., is the wearing of soft padded gloves 
without fingers, in order to hamper prehensile movements. The 
gloves are fixed by means of locked straps round the wrists. 
This mode of treatment should also be resorted to as little as 
possible, but it is less irritating than being held by the nurses. 
As in the case of seclusion, all occasions of mechanical restraint 
must be reported to the Board of Control. 

Food and Feeding.—Loss of appetite is one of the commonest 
symptoms in all acute forms of insanity, while overfeeding is 
one of the most important indications in the treatment. All 
food ought therefore to be of the best, nicely cooked, made as 


FOOD AND FEEDING 543 


palatable as possible and served in a dainty, enticing way. 
Ten shillings or less per week per patient is not enough to spend 
on food. Quite apart from our duty to the patients such 
economy is a shortsighted policy which causes many to become 
a life-burden on the rates. On a few occasions within the 
author’s experience the Bethlem authorities have broken their 
twelvemonth rule and admitted from county asylums cases of 
apparently chronic mania and melancholia of more than three 
years’ duration. By persistent good feeding and careful treat- 
ment these have rapidly recovered. 

As to the constituents of a good diet, much nonsense is talked 
nowadays concerning what we should eat. An ordinary English 
breakfast, dinner, tea and supper of good food in ample propor- 
tions, amplified proportions for the acutely insane, serve their 
purpose excellently well. The addition of three pints of milk 
per diem, perhaps with superadded cream, may be regarded as 
the specific medicine for these patients. A glass of wine with 
meals often improves the appetite wonderfully and it has the 
advantage of promoting absorption by the gastric mucous 
membrane. 

It is, of course, quite permissible to practise economy in the 
feeding of those who have become chronic and undoubtedly 
incurable. They do not need the extra food. Vegetative de- 
ments who do no work require less than a normal individual. 
Their taste is not refined and it can do no harm to supply 
them with the cheapest food on the market, provided it is 
wholesome. 

In the ordinary way, patients who refuse food are to be fed 
with a spoon by the nurses; but these should not be allowed 
to pour fluid nourishment down the patient’s throat with the 
feeding-cup, a pernicious utensil and a fertile source of pulmonary 
abscess and gangrene. 

If the refusal of food becomes so active that the nurses are 
no longer able to administer sufficient nourishment by means of 
a spoon, it is necessary for the patient to be tube-fed. Tube- 
feeding is carried out in the following way: With a funnel 
attached, a stiff indiarubber feeding-tube is passed into the 
stomach, a No. 10 vid the nose or a No. 20 vid the mouth gagged 
open if necessary. By this means the patient is fed with a pint 
of milk, four ounces of cream, and two eggs. The process may 
have to be repeated three or four times a day for months together. 
Sleeping-draughts and aperients may be administered with the 
food at the same time; it matters not how the mixture tastes 


544 MIND AND ITS DISORDERS 


when passed through a tube, for the patient is then unable eS 
appreciate its flavour. 

Some patients are able to prevent the fluid from entering the 
stomach by keeping the abdominal walls tense. This difficulty 
may be overcome by the use of a Higginson’s syringe, the nozzle 
being inserted into the end of the feeding-tube, while the other 
end lies in the food. 

Care must be exercised to avoid all possibility of food enter- 
ing the larynx during tube-feeding. If the patient regurgitates 
gastric contents by the side of the tube into the pharynx, the 
tube and gag must at once be withdrawn; for it is impossible 


Fic. 86.—PROLONGED BATH. 


The wooden cover, with an aperture for the head, is screwed on top of an 
ordinary bath. This is, however, usually dispensed with nowadays. 


for him to swallow the fluid under such circumstances and the 
only other way of disposing of it is to inhale it. And in all cases 
of tube-feeding, when the tube is withdrawn, be careful to keep 
the funnel low so as to siphon the last few drachms of milk, 
which may be left in the tube, away from the pharynx. 

The indigestion of many patients who refuse their food may be 
much ameliorated by stomach lavage with a dilute solution of 
bicarbonate of soda, carried out daily as a preliminary to the 
first feed every morning. 


MEDICINES 545 


Hydrotherapy.—This is useful mainly in three forms: the 
prolonged bath, the douche and needle baths and the wet pack. 
The prolonged bath has already been described in the treatment 
of acute mania; it serves the purpose of inducing the habit of 
rest in all cases of acute excitement. The douche and needle 
baths often serve as a beneficial stimulus to certain stuporose 
patients; they should not be employed if the patient suffers 
from cyanosis or cedema of the hands and feet or before his 
general nutrition has been considerably improved. A cold plunge 
is often useful for acute confusional cases during convalescence. 

The wet pack is a procedure to be employed only with the most 
extreme caution and circumspection, since it is rather exhausting 
and tends to raise the patient’s temperature. It is used to subdue 
excitement of such a violent character as is likely to prove 
dangerous, but should not be resorted to unless he is in fairly 
good physical condition. It consists of wrapping him in a sheet 
wrung out of water as hot as can be borne, and outside this is 
a dry blanket. He remains in this sort of general fomentation 
for about twenty minutes to half an hour, during which time it 
is well to keep up a supply of cold applications to the head. 

Medicines.—Of all the drugs employed in the treatment of 
mental disorder hypnotics are those most frequently used. Their 
name is Legion and I suppose that no physician has had ex- 
perience of them all. Certainly I have not; but I give my 
experience of the sleeping-draughts in most common use. 

Paraldehyde is a drug which produces sleep within a quarter 
of an hour and its effects pass off rapidly, within two hours. 
It is therefore the drug which one selects for those patients 
who have difficulty in getting off to sleep but whose sleep, when 
once started, continues for a reasonable number of hours. Its 
. nauseous flavour and the objectionable odour which it imparts 
to the breath during the following day are its chief disadvantages, 
but in some cases it also impairs the appetite and in others its 
continued use is rather liable to induce a mild bronchitis. It is 
a cardiac stimulant. The initial sleep is profound, sufficiently 
so to allow of mild operations being painlessly performed on a 
patient under its influence. The dose is 2 drachms, but double 
that quantity may be administered without doing any harm. 

Amylene hydrate acts even more quickly than paraldehyde. 
Its effect is more prolonged (six to eight hours). It has the addi- 
tional advantage of being less nauseous than paraldehyde. It 
has a somewhat unpleasant camphoraceous taste, but this does 


not hang about the mouth after the draught is swallowed. The 
3, 


546 MIND AND ITS DISORDERS 


dose is 14 drachms in an ounce of water. Two drachms is too 
large a dose, as the profundity of sleep then becomes rather 
alarming. 

Dial is a hypnotic made by the Clayton Company into 
tablets. Its action is not quite so rapid as that of amylene 
hydrate, but it is similar in other respects. One and a half or 
two tablets is a suitable dose for most patients. It is my experi- 
ence that, when the right dose for a patient is found, either a 
greater or smaller one is less efficient. Dial restores the sleep 
habit so effectively that gradual reduction of the doses causes the 
patient little or no distress and this can easily be carried out 
because the tablets are so constructed that they can be divided 
into quarters. Clinically dial appears to be a pure hypnotic with 
no other pharmacological action. 

Veronal is a useful hypnotic for patients who procure sleep 
of insufficient duration. If a patient, for example, gets four 
or five hours without the use of drugs, veronal in doses of 7 or 
8 grains will give him another two hours. If, on the other 
hand, he procures very little normal sleep, veronal is useless 
in such small doses; and if a dose sufficiently large to give him 
a good night (14 or 15 grains) be administered, he is sick next 
day. I have not experienced any other untoward results with 
veronal. 

Medinal (sodium-veronal) is a more certain hypnotic, gives 
the patient more sleep, and does not produce sickness or other 
troubles. It acts better with some people than with others and 
it is often useful in allaying agitation. Some doctors give as 
much as 30 grains without any obvious detriment, but I seldom 
give more than 15 and usually prescribe 7 or 8 grains. 

Soneryl (Butylethylmalonylurea) is the latest addition to this 
group. Itis put up in tablet form. Ihave not much experience 
of it so far, but it appears to be an improvement in that its 
action is more rapid and lasting and it does not cause indigestion. 
It is also said to alleviate pain. The most usually effective dose 
appears to be two or three tablets. 

Sulphonal still maintains an honourable place in the list of 
hypnotics in spite of its tendency to produce haematoporphy- 
rinuria on repeated administration for long periods. Its action 
is delayed and it should therefore be given three or four hours 
before bedtime. In some cases of obstinate insomnia it may not 
act at all for the first two or three nights; but, after that, it 
becomes more and more effectual. It has the advantage of being 
a motor sedative and is therefore almost a specific for acute 


MEDICINES 549 


mania. For the prevention of hematoporphyrinuria and to aid 
the action of the drug it is recommended that its administration 
be followed by a draught of Contrexéville water. Sulphonal 
tends to produce irritability of temper in some young patients, 
but it usually suits old people. The usual dose is 20 to 30 grains. 

Isopral in doses of 20 to 30 grains is a good hypnotic and a 
motor sedative. It has none of the bad after-effects of sulphonal; 
but it must be borne in mind that it is a vesicant, and should 
not be given in water. It is best administered in a teaspoonful 
of jam. 

Lrional is in my experience a poor hypnotic for insane patients 
and I have entirely discontinued its use since Soukhanoff stated, 
in a paper on degeneration of the neuron in animals, that he 
found this to be the most effective drug for producing neuronal 
degeneration. 

Chloralamide, too, I regard as practically useless for the insane; 
but it may be helpful to neurotic patients. 

Chloral hydrate is a good hypnotic which acts quickly and has, 
as a rule, no bad after-effects. It is suitable only for depressed 
patients since it has a tendency to increase motor excitement. 
It does not find much favour among physicians who have to 
treat the insane, because its depressing effect on the heart and 
respiration 1s somewhat dreaded. 

Opium is still one of the best hypnotics we possess and it, or 
its alkaloid morphia, may have a beneficial effect on the nervous 
system in some agitated cases of melancholia. Indeed, at one 
time doctors used to talk of the “opium treatment of melan- 
cholia ’’, as if they had found a specific remedy for that disorder. 
The drug does not, however, find much favour as a hypnotic for 
the insane, partly because opium makes many of these patients 
sick, but chiefly because it increases constipation, which is already 
troublesome enough among these patients. 

Other medicines required in the treatment of mental patients 
are those used to build up the general health. Anemia, constipa- 
tion and indigestion are to be treated on general medical prin- 
ciples, the discussion of which would be out of place in a manual 
of this nature. 

Masturbation is a symptom which often requires treatment. 
Devices for its prevention have been invented from time to time, 
but none of them serve their purpose, for the reason that they 
attract the patient’s attention to the very part which already 
dominates his consciousness too much. The best sexual sedative 
for the masturbator and one which often serves to break the habit 


548 MIND AND ITS DISORDERS 


is an emulsion containing a drachm of the extract of black willow 
and 5 grains or more of monobromate of camphor and of sodium 
bromide to each dose. This may be given three times a day after 
meals. Extract of Jamaica dogwood is also recommended. 

In out-patient practice at St. Thomas’s Hospital I find that 
sodium bromide is a helpful drug to most neurotic and psychotic — 
patients. The usual dose is about Io grains three times a day 
with a couple of minims of liquor arsenicalis to prevent a bromide 
rash. As we have seen in earlier chapters, many neurotic 
symptoms are a distorted method of gratifying some unrecognized 
perverse sexual complex and I hold the view that the beneficial 
action of the bromides is due to the fact that they are an- 
aphrodisiacs. 

Prevention of Suicide.—There is only one means of preventing 
suicide, viz., constant observation. The physician learns by 
experience to recognize which patients are suicidal and which 
may be trusted and he must tell the nurses. clearly when a 
patient is suicidal and not to be allowed out of sight. Some very 
suicidal cases require the whole attention of one or more nurses. 
Patients must not be allowed access to dangerous weapons or 
articles with which they can strangle themselves, and the fire 
must be protected. Apart from such precautions as these, we 
have to rely on the intelligence of the attendants and it should 
be the object of all institutions to increase the intelligence of the 
nursing-staff by instruction and by the removal of those who are 
incapable of instruction and learning from experience. The 
writer is strongly opposed to the practice of making rooms and 
wards in which patients have to live for long periods of their lives 
unsightly and prison-like with the object of doing away with 
every conceivable means of suicide. For one thing this cannot 
be done and, for another, it tends to decrease the sense of 
responsibility of the personnel. 

Visits and Letters from Friends.—A difficulty which often arises 
in the treatment of the insane is interference on the part of the 
friends of the patient. It is with the utmost difficulty, in the 
majority of cases, that these can be made to realize that mental 
disorder is a definite disease and they believe themselves, in 
common with the rest of mankind, to be perfectly qualified to 
treat insanity.* For them any person suffering from mental 
disorder is either an imp of wickedness or a lazy scoundrel and 


* Many physicians qualify themselves for this work by saying that they 
treat only borderland cases. If they adhered to this principle and referred 
their mental cases to a medical psychologist, which they do not, incar- 
ceration in an asylum might more frequently be averted. “ 


CONVALESCENCE 549 


they have no patience with any person who is “ fool ” enough to 
believe things which are manifestly untrue. 

Accordingly they seize upon the opportunity of their visits to 
scold the patient for daring to be depressed or excited and to 
threaten him with imprisonment for life or something worse by 
way of an antidote to his delusions. Letters are no better. 
Instead of words of encouragement they contain threats of 
desertion and of other dire consequences in the event of the 
patient persisting in his delusions. Of course such methods are 
most detrimental to his progress and if, after due explanation 
and warning, his “ friends ”’ continue to worry him in this way, 
there is no other course open to the physician than to put a stop 
to visits and letters. Fortunately, the friends of the patients 
are not all so foolish, and some do a great deal of good. I regret 
to say that this is the exception. An observant physician will 
soon learn which patients are worse after ‘‘ visiting-day ’’ and he 
will act accordingly. Matters are even worse when the patient 
is being nursed at home. The work of the nurses is usually 
rendered extraordinarily difficult on account of suspicion. What 
the relatives or friends suspect I know not and it is certain that 
they themselves do not know. 

In institutions also the friends are often suspicious that there 
is something sinister in the treatment of the patient; they will 
examine and cross-examine the doctor, the matron, the sister 
of the ward, the nurses and even other patients respecting the 
treatment in general and that of the patient in whom they are 
interested in particular. Should any discrepancy transpire it is 
clear evidence that some underhand business is being concealed; 
then there is trouble. In any other situation the person in authority 
would insist on the removal of the patient, but here it would not 
be fair to the patient—it would be bad treatment. Bearing such 
considerations in mind, the doctor has to exhibit much tact and 
discretion in solving individual problems in the best way. 

Convalescenee.—When convalescence is established, the patient 
may attend “ associated entertainments ’’ and be encouraged to 
take exercise. He is allowed to go out for walks, at first with 
a nurse, then with his own friends if they are trustworthy. Later 
he may be permitted to go for walks by himself, after having 
given his word (‘‘ parole ’’) to return to the institution at a given 
time and to abide by any restrictions which the physician may 
think wise to bestow on him. Finally, before leaving the insti- 
tution, the doctor should advise him as to his subsequent mode 
of life with a view to preventing the recurrence of his disease. 


CHAPTER XXEX: 
THE INSANE AND THE LAW. 


[The revision of this chapter for the present edition has been kindly 
and very thoroughly carried out by W. H. Gattie, Esg., K.C.] 


In the majority of cases of mental disease the patient either has 
no insight into the nature of his condition or, if he has, is un- 
willing or unable to make up his mind to place himself under 
care and treatment. Accordingly it becomes necessary for his 
friends or relatives to place him under care against his will, 
either in his own interest or for the sake of the public. Now 
the law will allow such trespass against the liberty of a subject 
under certain conditions only. These will be considered in the 
present chapter and we shall further have to study the extent to 
which the law will allow a patient mentally diseased to exercise 
certain civil rights and how far it will excuse him from his civil 
and criminal responsibility. 

The carrying out of the Lunacy Acts and Mental Deficiency Act, 
so far as concerns the care and treatment of patients, is largely 
entrusted to a Board of Control consisting of a Chairman, Secre- 
tary and not more than fifteen Commissioners, two of whom are 
ladies. The Secretary and four of the Commissioners must be 
barristers or solicitors and at least four are medical men. 

All institutions for the reception of patients suffering from 
mental disease who, under the law, are spoken of as “‘ Lunatics ”’, 
‘“ Persons of Unsound Mind ”’ (non compos mentis) or “‘ Mentally 
Defectives’”’ are under the jurisdiction of the Board of Control. 
These institutions are of four classes: 

1. Licensed Houses.—Fach of these is the property of one or 
more private individuals or private limited company who for 
a fee (£15 or more annually, according to the number of patients 
accommodated in the institution) obtain for their house a licence 
which must be renewed from year to year. To comply with the 
law one of the licensees must be resident in the house. In 
London and a specified surrounding area such institutions receive 
at least six visits every year from the Commissioners. Outside 
this area licensed houses receive annually two visits from the 

55° 


ESTABLISHMENTS FOR THE INSANE Gov! 


Commissioners and four from justices of the peace appointed 
under the Lunacy Act. 

The friends of the patient pay for his maintenance in the 
institution, the fee varying usually from three to twelve guineas 
weekly according to his requirements. In the grounds of some 
licensed houses there are suitable villas where a patient may be 
treated and attended by a complete staff of nurses and servants; 
under such circumstances the weekly payment reaches £50 or 
more. 

2. Registered Hospitals are self-supporting and usually en- 
dowed institutions for the treatment of private patients, the 
funds being under the control of a committee of visitors. Fees 
from paying patients are utilized purely for the maintenance 
of the hospital and not for the personal profit of any private 
individual. Hospitals in Home Counties are visited twice a 
year by the Commissioners, those in the provinces once a year. 
Annual registration is not required. 

3. Public Asylums (now generally described as Mental Hospitals, 
but which must not be confused with the Registered Hospitals 
described in the preceding paragraph).—These are the county 
and borough asylums erected and maintained out of the rates 
for the treatment of pauper lunatics; the State Criminal Asylum 
at Broadmoor, erected and maintained by the State, the patients 
being paid for out of the rates of the borough or union to which 
they are chargeable; also the Royal Military Hospital at Netley 
and the Royal Naval Hospital at Great Yarmouth, both erected 
and maintained by the State. Some of the county and borough 
asylums receive a few private patients and all of them, as well 
as the registered hospitals and even licensed houses, may receive 
“ criminal lunatics ’’. All public asylums are visited once a year 
by the Commissioners. 

4. The various Institutions and Approved Homes etc., under 
the Mental Deficiency Act, for the reception and treatment of 
idiots, imbeciles and other classes of the mentally defective. To 
accommodate the large class of people who are anxious tb spare 
their friends and relations the stigma of detention in an asylum, 
registered hospital or licensed house, the law allows one insane 
patient to be detained and treated in a private dwelling for profit, 
provided he is certified and reported to the Commissioners in 
Lunacy. Under such circumstances the house is liable to be 
visited by one of the Commissioners at any reasonable time, when 
he must be afforded facilities for seeing any part of the house. 
More than one certified patient in a private dwelling is disallowed, 


552 MIND AND ITS DISORDERS 


unless the Commissioners grant a special permit for the reception 
of two or more such patients. 

A patient suffering from uncertifiable mental disorder may 
voluntarily place himself for treatment in any house or institution 
whose occupants are willing to receive him for profit; and a 
certifiable patient may be detained and treated under the com- 
mon law (7.e., uncertified) against his will in any house or insti- 
tution whose occupants are willing to receive him, provided 
this is not done for profit. Although a person receiving a 
patient under such circumstances is not liable under the Criminal 
Law, it must not be forgotten that he runs the risk of a subse- 
quent civil action brought against him by the patient. The 
position of affairs is that it is only safe to detain an uncertified 
patient under such circumstances when he is dangerous either 
to himself or to others, and then merely as a temporary measure 
pending certification. 

There is no provision at present for voluntary boarders in 
public asylums, but an uncertifiable patient may place himself 
for treatment in a registered hospital or licensed house on the 
understanding that he may be allowed to leave within twenty- 
four hours of giving notice to do so. In the case of a licensed 
house the intending boarder must first obtain from the Board of 
Control (or two local justices if the house is in the provinces) 
their consent, which may be given for a specified time only. It 
is not necessary for intending voluntary boarders in licensed 
hospitals to apply to the Board of Control. After the admission 
of a voluntary boarder, notice of the same must be sent to the 
Board of Control within twenty-four hours. 

The following are the modes of procedure by which a patient 
may be placed under care, usually against his will: 


1. Reception Orders on Petition. 
2. Urgency Orders. 
3. Summary Reception Orders for 
(a) Lunatics wandering at large. 
(b) Pauper Lunatics. 
(c) Lunatics who are not under proper care and control or 
are being cruelly treated or neglected. 
4. Reception Orders by a Commissioner to the Board of Control. 
5. Reception Orders by the Home Secretary (used in criminal 
cases, vide p. 565). 
6. Orders after Inquisition. 


Reception Orders on Petition.—This is the ordinary mode of 
procedure for private patients. The necessary documents are a 


MODES OF PROCEDURE AS 


petition, statement of particulars, two medical certificates and 
an Order. 

The Petition is a document asking some particular County 
Court judge, stipendiary magistrate or justice of the peace 
(specially appointed under the Lunacy Act) to make an order 
for the reception of the patient into a particular asylum, hospital, 
licensed house or private dwelling. It must be signed, whenever 
practicable, by the husband, wife or a relative of the patient, 
who must have seen him within fourteen days of the presentation 
of the petition. If any other person sign the petition, the reason 
must be given. In any case the petitioner must be above twenty- 
one years of age. 

The Statement should also be signed by the petitioner, but if 
it is not so signed, any other person is eligible to sign it, provided 
details of address, occupation and conditions under which such 
person signs are inserted where indicated on the form. It con- 
tains particulars as to the name, age, sex, civil state etc. 

One of the medical certificates must, whenever practicable, be 
signed by the usual medical attendant, unless he be related to the 
patient or the petitioner. Neither certificate may be signed by 

(1) The manager of the institution receiving the patient or the 
person who is to have charge of a single patient; 

(2) Any person interested in the payments on account of the 
patient; 

(3) Any regular medical attendant of the institution ; 

(4) The husband or wife, father or father-in-law, mother or 
mother-in-law, son or son-in-law, daughter or daughter-in-law, 
brother or brother-in-law, sister or sister-in-law or the partner or 
assistant of any of the foregoing persons. 

If it be desired that the usual medical attendant continue to 
attend the patient, it is held by the Board of Control (but their 
opinion may be disputed) that neither he nor his partner may sign 
either of the certificates; he must certainly have no monetary 
interest in the house to which the patient is sent. 

The medical practitioners signing the certificates must, for 
purposes of certification, examine the patient separately and at 
a time not exceeding seven clear days before the presentation of 
the petition to a justice. 

The certifying practitioner is required to state facts observed 
by himself at the time of examination and he is at liberty to add 
facts communicated by others. He should confine his statement 
to facts which, considered either individually or in relationship 
to one another, are such strong evidence of insanity that he 


554 MIND AND ITS DISORDERS 


would be willing to be cross-examined on them in a court of law. 
Irrelevant statements, expressions of opinion and records of 
physical signs should find no place in a certificate. For example, 
the following, culled from the certificates at Bethlem, should 
have been omitted: ‘‘ His demeanour indicates an unhinged 
mind ”’; “‘ Wild look in his eyes ’’; “‘ Speaks lucidly at intervals ”’; 
“ Patient’s tongue is tremulous and his articulation is indistinct ”’; 
“ Patient says I am a fool”’. } 3 

No medical man is bound to sign a certificate; but, if he does 
so, he must remember that any wilful misstatement is a mis- 
demeanour. If he acts in good faith and with reasonable care 
he is not properly liable to any civil or criminal proceedings. 
If such proceedings are taken against him, they may be stayed 
on summary application to the High Court, provided that the 
Court is satisfied that there is no evidence either of lack of good 
faith or non-exercise of reasonable care. 

The Order, authorizing some person to receive the patient into 
his institution or house, may be signed by a judicial authority 
(t.e., a judge of a County Court, a stipendiary magistrate or a 
justice of the peace specially appointed under the Lunacy Act, 
1890) with or without seeing the patient, after he has perused 
the petition, statement and certificates. 

Should the judicial authority wish to see the patient before 
signing he must appoint a time within seven days for doing so. 
Having seen him he may either sign the order forthwith or again 
postpone the matter for a period not exceeding fourteen days. 

When a patient is admitted to an institution or house without 
having been seen by a judicial authority the superintendent or 
medical attendant must give notice in writing to the patient that 
he has a right to be visited by a judicial authority and, if the 
patient desire it, cause a judicial authority to visit him; or, if 
the medical attendant considers that this would be prejudicial 
to the patient, he must send to the Board of Control a certificate 
to this effect. In practice the judicial authority is nearly always 
a justice of the peace, but he must not be the judicial 
authority who signed the Reception Order for the patient’s 
detention. 

It is obvious that the above procedure, even at the shortest, 
takes some considerable time, probably two or three days; but 
in certain cases, especially those in which the patient is dan- 
gerous to himself or others, it is desirable that he should be 
placed under care forthwith. This may be done by making use 
of the Urgency Order. 


THE JUSTICE’S ORDER DDD 


Urgeney Orders.—In this mode of procedure no petition is 
necessary; authority to receive the patient is granted, whenever 
practicable, by the husband or wife or a relative of the patient. 
When it is granted by any other person the reason for the de- 
parture must be given. The person signing the order must 
have seen the patient within two days of his admission to the 
institution. The order must be accompanied by a statement of 
particulars, similar to that accompanying a petition, and by one 
medical certificate. The certifying medical practitioner must 
have seen the patient within two clear days of his signing the 
certificate. This certificate differs from the ordinary schedule 
form in that it must contain a clause giving the reasons for 
urgency. An Urgency Order remains in force seven days, or if 
a petition for a Reception Order is pending, until the petition is 
finally disposed of. In practice a Reception Order on Petition 
has to be completed within seven days of the signing of the 
Urgency Order. 

Summary Reception Orders.—Every constable, relieving officer 
or overseer of a parish, who has knowledge that any person within 
his district, who is not a pauper and not wandering at large, is 
deemed insane and is not under proper care and control or 1s being 
cruelly treated or neglected, shall within three days give information 
on oath to some judicial authority under the Lunacy Act, usually 
a justice of the peace. The justice shall then direct two medical 
practitioners to examine the patient and certify as to his mental » 
state. If these certify that the patient is insane and a proper 
person to be detained under care and treatment, the justice may 
sign an order for his removal to a house or institution for the 
insane. The documents used in this mode of procedure are the 
same as those for a Reception Order on Petition, except that there 
is no petition. 

Orders for Pauper Lunatics and Lunatics wandering at Large.— 
The law enacts that such persons be apprehended by the local 
constable, relieving officer or overseer of the parish and that 
they be taken before a justice. In practice the patient is taken 
to the infirmary of the union in which the patient is apprehended 
and is there visited by a justice. If the justice considers the 
patient to be insane, he directs that he remain under observation 
in the infirmary for a period not exceeding fourteen days. H, 
at the end of this time, he considers the patient still insane, 
he directs a medical practitioner (usually the medical officer 
of the infirmary) to examine the mental state of the patient. 
If the medical practitioner certifies that the patient is insane, 


556 MIND AND ITS DISORDERS 


the justice makes an order for his reception into an institution 
for lunatics, unless the medical officer certifies in writing that 
the patient is a proper person to be detained as a lunatic in a 
workhouse. It will be observed that only one medical certificate 
is necessary in the case of pauper lunatics and lunatics found 
wandering at large. 

Order by a Commissioner.—Any one or more Commissioners 
may visit a patient, not in a workhouse or institution for lunatics, — 
call in a medical practitioner and, if he certifies the patient to be 
insane, order him to be removed to an institution for the insane. 

Orders after Inquisition.—A person found lunatic by inquisition 
may be received on an order signed by a Committee of the 
person of the lunatic, or if no Committee has been appointed, 
then on an Order by a Master in Lunacy. 

Judicial Inquisition as to Lunacy.—The Judge in Lunacy 
may, upon application, by order direct an inquisition whether a 
person is of unsound mind and incapable of managing himself 
and his affairs. The patient may claim and is entitled to be 
examined before a jury. The inquiry is limited to things said 
and done by the patient within two years of the inquisition. 
The chief witnesses are medical men including those who have 
signed certificates and affidavits with regard to the mental con- 
dition of the patient and usually others who may be called as 
expert witnesses for both sides. These are examined and cross- 
examined on oath before a judge or Master in Lunacy, either in 
open court or in private, just as in an ordinary trial. 

The jury may return one of three verdicts: 

1. That the patient is capable of managing both himself and 
his affairs. 

2. That he is incapable of managing either himself or his 
affairs. 

3. That he is capable of managing himself but incapable of 
managing his affairs. 

The contingency of a person being capable of managing his 
affairs but not himself does not occur. If the jury find ver- 
dict (2), the Master in Lunacy appoints a ‘“‘ Committee of the 
Person’”’ and a ‘‘ Committee of the Estate’’, who may be one 
and the same person. The patient is thenceforth known as a 
“Chancery lunatic’”’ and he is regularly visited by one of the 
Lord Chancellor’s visitors, one of whom is a barrister-at-law and 
two are medical men. If verdict (3) is returned, the Master 
appoints a “‘ Committee of the Estate ”’ but not a “‘ Committee of 
the Person ’’; and the patient is free to go about as he chooses. 


MENTAL DEFECTIVES 57 


In practice, an Inquisition in Lunacy is now almost obsolete. 
This change came about owing to the operation of the Lunacy 
Act, 1908, which conferred upon a “ Receiver ’’ the same powers 
as to management of property as was previously vested in the 
Committee of the Estate. The person appointed as a Receiver 
is generally a near relative of the patient, but he should not be 
in any fiduciary relationship. If no desirable relative is available, 
or if no intimate friend comes forward and applies to be appointed, 
the Official Solicitor to the Royal Courts of Justice is generally 
called upon and duly appointed. The appointment of a Receiver 
is far less costly than an Inquisition in Lunacy. 

The procedure for placing a mentally defective person under 
care in an institution or house approved for mentally defectives 
is similar to the Reception Order on Petition under the Lunacy 
Acts, with two important differences. One is that the petition 
must be accompanied by a Statutory Declaration by the parent 
or guardian and some other person that 


(1) The patient is a defective within the meaning of the Act 
(the Mental Deficiency Act, 1913). 

(2) He is subject to be dealt with under the Act by reason 
of certain specified circumstances. 

(3) A petition has or has not been made under the Lunacy Acts. 

(4) A medical examination is impracticable, the reasons being 
given. 


The other difference is that one of the medical certificates must 
be made, not necessarily by the usual medical attendant of the 
defective, but by a medical practitioner in possession of a certi- 
ficate of approbation under the Act, either by the local authority 
or by the Board of Control. 

In the case of feeble-minded persons and moral imbeciles 
over twenty-one years of age, a full Reception Order on Petition 
is required; but no Order by a Justice is required for an idiot 
or imbecile of any age. Procedure is therefore simplified if the 
doctor can certify that the patient is an imbecile, rather than 
a feeble-minded person. 

The wording of the schedule differs but slightly from that of 
the Lunacy Acts. 


Returning to the subject of the detention of persons of unsound 
mind under the Lunacy Acts, the following particulars must be 


observed :— . 
Within one clear day of the reception of any patient into an 


558 MIND AND ITS DISORDERS 


institution or private house notice of the same must be sent to 
the Commissioners, together with a copy of the admission 
papers. 

Not less than two days and not more than seven clear days 
after the reception a medical statement as to the mental and 
physical condition of the patient must be forwarded to the Com- 
missioners. Another similar report must be sent at the expira- 
tion of one month. In the case of patients in single care such a _ 
report is also required by the Board of Control during the week 
following January Io in each year. 

A Reception Order expires at the end of one year from its 
date. If it is desired to keep the order in force for a further 
period, a special report as to the mental and physical condition 
of the patient must be sent to the Board of Control not more 
than one month or less than eight days before the expiration of 
the Order, together with a certificate that the patient is still of 
unsound mind and a proper person to be detained under care and 
treatment. Similar reports and certificates must, if necessary, be 
sent at the expiration of the second, fourth and seventh years 
and, after that, every five years. 

These continuation certificates are not required in the case of 
criminal patients detained by order of the Home Secretary. 
The regulations with regard to these certificates are varied in the 
case of ‘‘ Lunatics so found ’’ (Chancery Patients). 

When a patient recovers or is otherwise discharged or removed, 
notice must at once be sent to the Board of Control. 

The manager of an institution may, if he think fit, grant 
forty-eight hours’ leave of absence to any patient under his care. 
For longer periods permission is granted by the Committee of 
Visitors in the case of registered hospitals and public asylums, 
by the Board of Control in the case of licensed houses within their 
immediate jurisdiction and by the justices in the case of licensed 
houses in the provinces. 

Transfer.—No certified private patient may be transferred 
from one institution to another without the consent of the Board 
of Control. The Board has the power to allow the transfer of a 
patient from a public asylum to a licensed house and from the 
pauper to the private class. It will be seen that, in such circum- 
stances, a private patient may be detained on one medical 
certificate. 

Escape.—If a patient escape, he may be recaptured at any 
time within fourteen days and detained on the original order 
and certificates. In the case of a Chancery patient notice of 


LEGAL CAPACITIES AND RESPONSIBILITIES 559 


such escape should be sent to the Lord Chancellor’s Visitors. 
It is no longer necessary to notify an escape to the Board of 
Control. . 


LEGAL CAPACITIES OF THE INSANE. 


1. As Witnesses.—As a general rule the insane are regarded as 
incompetent to give reliable evidence; but the law allows the 
presiding judge to decide the matter in each individual case and 
it is left to the jury to determine how much importance they will 
attach to the evidence of an insane person. 

In the case of written evidence (affidavits) a preliminary 
inquiry must be held to determine whether the person’s insanity 
is of such a nature as to render unreliable his evidence upon the 
particular matter under consideration. 

2. As Testators.—For a will to be valid the law requires the 
testator to have a “sound disposing mind”’ either at the time 
when he gave instructions for the will to be prepared or at the 
actual moment of its execution; it is not necessary that he 
should have a “ sound disposing mind ”’ on both occasions. 

It is immaterial whether the testator is a person “so found ”’ 
as a lunatic or not. If he be his capacity varies from other 
insane persons, when dealing with the law of contract only. 
The reason is that a will operates after the death of the testator, 
when the Lord Chancellor’s control has ceased to exist, whereas 
the operation of a contract comes into being iter vivos during the 
Lord Chancellor’s control. 

It often falls to the lot of a medical man to examine a patient in 
order to decide whether he is of a sound disposing mind. When 
called upon to do so he should make written notes of the examina- 
tion; and he should endeavour to ascertain 

(a) Whether the patient understands the nature of the will; 

(6) Whether he understands the nature of the gift; 

(c) Whether the patient is capable of enumerating, on the one 
hand, the details of his estate and, on the other, the individuals 
who have any reasonable claim to benefit from it ; 

(d) Whether there appears to be any person who has exercised 
undue influence on his decision ; 

(e) Whether the patient is suffering from any delusion which 
might influence his decision and whether he has any insane 
dislike to or suspicion of any member or members of his family, 
who might in the ordinary course become beneficiaries ; 

(f) Whether he has any delusion respecting his property, which 
might influence his decision ; 


560 MIND AND ITS DISORDERS 


(g) Whether, having once announced his decisions, he is 
capable of recapitulating them, say a few days later. 

These are the main points upon which the medical man will be 
cross-examined should he be called upon to give evidence when 
the will is disputed. 

The law upholds a will made from eccentric, frivolous or 
Capricious motives, provided it can be shown that the will repre- 
sents the true wishes of the testator and was not the result of — 
an eccentricity, frivolity or caprice of the moment amounting 
to such a state of unsoundness of mind as would deprive the 
testator of his testamentary capacity. 

It is the rule at law that an idiot cannot make a will, because 
he has no disposing mind—an imbecile “may” have a dis- 
posing mind, but generally he would not be so regarded. There 
are many forms of imbecility, but there is only one form of 
idiocy. It is here convenient to state that whilst the law regards 
an idiot as irrecoverable, such a principle is not applied to insanity. 


CIVIL RESPONSIBILITIES OF THE INSANE. 


Contracts.—The occurrence of insanity does not excuse the 
patient from the performance of a contract made previously 
to his becoming insane. 

Contracts for “‘ necessaries ’’ made by an insane person may 
be binding. By the term “ necessaries ’’ is meant such articles 
as clothing; but the term is an elastic one and it is left to the 
judge and jury to decide what articles are “‘ necessaries ’’. 

An insane person, not so found by inquisition, or a person 
who is drunk may make contracts for other than necessaries. 
These may be binding unless the contract is of such a nature 
that it would not have been made but for the unsound mental 
condition at the time of making the contract. Even in such a 
case the validity of the contract might depend, either upon the 
knowledge of the insanity by the other contracting party, or of 
the presumption of knowledge which such other party might be 
held to have. 

On the other hand a contract is frequently binding on the 
second party whether he knew of the insanity or not, except in 
the case of a marriage contract. In the latter case the Divorce 
Court will grant a decree of nullity of marriage on application 
of the second party provided it can be shown that he was not 
aware of the insanity at the time of the marriage. Insanity 
occurring subsequently to marriage is no ground for divorce. 


) 


CRIMINAL RESPONSIBILITY 561 


It may be well to add, that the existence of delusions, even if 
such delusions are known as such, to the other contracting party 
will not necessarily invalidate a contract, unless such delusions 
are held to extend to the root of the contract. 

The decided cases with regard to the contracts of insane persons 
present so many points for discussion, that it is here impossible 
to attempt to give a full explanation of the legal intricacies with 
which the question abounds. Suffice it in conclusion to say that 
generally the law demands a higher capacity of understanding 
in the execution of a deed than in a case of a simple contract, 
more especially so in cases where the deed is contrary to the 
interests of the insane person. 

Torts.—A “tort’’ is an injury to the person, property or 
reputation of another, which renders the offender liable under 
the civil law but not necessarily under the criminal law. Libel 
and slander may be cited as examples of torts. Libel may under 
certain circumstances be punishable under the criminal law. 
Adultery also is a tort, because it is a wrong to the other party 
to the marriage. Theft, embezzlement, rape and murder are 
not torts; they are crimes. 

In English law insanity is not necessarily an excuse for a civil 
wrong. The injured party may be entitled to damages on the 
principle that every man is entitled to possess inviolate his 
personal security, liberty, property and reputation. The amount 
of damages is, however, left to the discretion of the jury and it 
is not likely that they will award heavy damages, say, in a case 
of slander in which the offender is known to be so insane that 
nobody would attach any importance to his statements. Every 
medical officer of a large institution for the insane is slandered 
by patients every week of his life, but such slander does him no 
harm, and an action for damages would be an absurdity. 


CRIMINAL RESPONSIBILITY. 


When a man commits a crime the law may demand that he 
shall be punished; but if the act was committed as the result of 
the direct action of another without any condition of mens rea 
on the part of the person committing the act the law is that this 
latter person who criminally started the train of circumstances 
which led up to the act, is responsible for the crime and must 
therefore be punished. This principle is well illustrated by the 
following extreme case which, although dealing with the law of 


torts, illustrates a principle of law which is convenient to quote 
cp 3 


562 MIND AND ITS DISORDERS 


In a certain market-place a man threw a lighted squib on to a 
stall, whose owner immediately threw it away so that it fell by 
accident on another stall. The owner of the second stall also 
threw it away and in so doing hit the plaintiff in the face and, 
the squib thereupon bursting, the plaintiff's eye was put out. 
It was held that the man who originally threw the squib was 
answerable to the man whose eye was put out, the ground for 
this decision being that he intentionally did an illegal and 
mischievous act which was likely to prove injurious to others, 
and must accordingly be held responsible for the direct and 
natural consequences which resulted from what he did, whether 
he actually intended them or not, and that the intermediate 
parties acted by necessity imposed on them by the defendant. 

Bearing this principle in mind, I suggest that a man who 
commits a crime as an indirect result of disease is not to be held 
responsible at law for his action. In this suggestion I am merely 
going a little farther back than the legal explanation—the lack 
of mens rea. The disease is in reality the responsible agent; 
accordingly the law deals leniently with a person who has com- 
mitted a crime but is proved to have been insane when he did it. 

At a time when public feeling was running high on account 
of the acquittal of one McNaghten who in 1843 shot Mr. Drum- 
mond, the private secretary of Sir Robert Peel, supposing that 
Mr. Drummond was Sir Robert Peel himself, whom the murderer 
wildly suspected of having some connection with an imagined 
system of persecution against him, the House of Lords summoned 
all the judges and put to them a series of questions. The 
answers to these constitute the highest expert legal opinion 
which has ever been obtained on the criminal responsibility of 
the insane. This opinion may be expressed as follows: If a 
person suffers from a delusion but is not otherwise insane, he is 
to be held responsible and punishable for his offence, unless he 
has acted in such a way as would have been permissible, had the 
facts about which his delusion exists been true. For example, 
if a man kills another whom he believes to be about to kill him 
(z.e., in self-defence), he is not to be held responsible; but if he 
kills another whom he believes to be robbing him, he is to be 
held responsible and punishable. In other cases it must be 
clearly proved, to establish a defence on the ground of insanity, 
“that, at the time of committing the act, the party accused 
was labouring under such defect of reason, from disease of the 
mind, as not to know the nature and quality of the act he was 
doing or, if he did know it, that he did not know he was doing 


CRIMINAL CASES 563 


what was wrong’’. The above is an authoritative expression of 
opinion on the way in which the law should be administered, 
and the judges of the present day, while they do not all consider 
the answers of the judges in 1843 as binding, find in them a 
sound working basis for their administration of the common law. 

In the light of experience these rules, so far as they go, seem 
very fair and just. It would certainly be an erroneous principle 
to make every form of insanity an excuse for crime. Everybody 
with a large experience of the insane knows that many of them 
take an unfair advantage of the fact, which they very soon 
learn, that they are immune from punishment and other natural 
consequences of their actions, so long as they remain in an 
institution for the insane. It would probably be wrong, for 
example, to allow a simple maniac who had shot his father to 
go unpunished: but if a person suffers from the delusion that his 
father is in imminent peril of undergoing some excruciating 
torture and kills him with the object of sparing him that torture, 
he is not to be held responsible for his action; because, at the 
time of committing the act, although he might know that what he 
was doing was legally wrong and punishable, he would consider 
that he was doing what was morally right. This point must be 
borne in mind by medical witnesses when they are asked, as they 
always are, whether the prisoner was capable of distinguishing 
right from wrong. The question does not mean “ Was the 
prisoner capable of distinguishing what is legally right from 
what is legally wrong ?’”’ It means ‘“‘ Was he capable of distin- 
cuishing what is morally right from what is morally wrong ?”’ 
Again, the question does not refer to the prisoner’s general know- 
ledge of right and wrong; it refers to his knowledge of right and 
wrong in respect to the very act with which he is charged. Asa 
matter of fact, the legal view of the above situation would be that 
the state of mind of the accused should be such as to justify the 
Court in excusing him from the penalty of his crime. 

The answers of the judges do not, however, in my opinion go 
quite far enough. They take no account of certain forms of 
mental disorder which, in the opinion of medical men, should 
excuse a prisoner charged with a crime from punishment. In 
particular, they take no account of the various morbid impulses 
occurring, for example, in the obsessional neurosis and in some 
forms of senile degeneration. Indeed, cases have actually occurred 
in which an old man, previously of high moral character, has 
been sentenced to a long term of imprisonment for some im- 
pulsive sexual offence, actuated by an incipient senile dementia 


564 MIND AND ITS DISORDERS 


(and also perhaps some irritation of an enlarged prostate), which 
could not be controlled by a brain whose degeneration is only 
too well confirmed by the subsequent history of the case. Apart 
from other considerations, prison life can hardly be regarded as 
a curative measure for such patients. 

I have had under my care several patients who came to Bethlem 
as voluntary boarders to be cured of a constantly recurring 
impulse to kill their children. Some of these have told me that 
if, by some mischance, one of their children had suddenly ap- 
peared in close proximity when they had happened to have a 
hatchet or a knife in hand the child would certainly have been 
killed before the parent could have had time to realize the awful- 
ness of his crime. Had such a thing actually happened, as it 
sometimes does, the man might, according to the existing state 
of the law, have been hanged. 

These morbid impulses have not, however, entirely escaped 
recognition by the Bench. Sir James Stephen expressed the 
opinion that the McNaghten case admitted as a further exemp- 
tion that “‘a person should not be punished for any act when 
he is deprived by disease of the power of controlling his conduct, 
unless the absence of control has been caused by his own default ” 
(I presume that this refers especially to alcoholism); and his 
opinion has been supported by the dicta of some other judges 
(four cases). The view is also substantially adopted in the 
Queensland Code of 1899 in the following clause: ‘‘ A person is 
not criminally responsible for an act if at the time of doing the 
act he is in such a state of natural disease or natural infirmity 
as to deprive him of capacity to understand what he is doing 
or of capacity to control his actions.”’ 

In the absence of legislation to the contrary, Courts of Law 
are not precluded from recognizing the existence of a form of 
mental disease which prevents the sufferer from controlling his 
conduct and choosing between right and wrong, although he may 
have the mental capacity to distinguish between right and wrong. 

In murder cases the medical expert seldom has an opportunity 
of examining the prisoner before he has been committed for 
trial. When the opportunity occurs, the expert should take 
down in writing everything the prisoner says, preferably in his 
presence. 

The magistrates, if they find evidence of guilt on the part 
of the accused, are bound to send him for trial; they have no 
power to discuss the question of sanity or insanity. Similarly, 
whenever there is any evidence of guilt, the grand jury are 


CRIMINAL CASES 565 


bound to find a “true bill’; they have no power to ‘‘ cut the 
bill” on the ground of insanity. 

When it is intended to set up insanity as a defence, arrange- 
ments are made for the medical witnesses to have one or more 
personal interviews with the accused. At these interviews they 
should take down in writing everything the prisoner says, prefer- 
ably in his presence. The Court always allows a medical expert 
to refer to such notes when giving his evidence, which must, of 
course, be quite impartial. 

In the High Court the question of insanity may be raised 
either on arraignment or during the course of the trial. On 
arraignment the jury may be asked (1) whether the prisoner is 
“able to plead or not”’, (2) whether he is “sane or not” or 
(3), when the prisoner is asked to plead “ guilty’”’ or “not 
guilty ’’, and he takes no notice, whether he is “‘ mute of malice 
or by the visitation of God’’. Lastly, if the question of insanity 
is raised during the course of the trial, the jury may be asked to 
state in their verdict whether they consider the accused “ sane 
or insane ’’. 

At whatever stage they find a prisoner insane, the judge 
makes an order for him to be kept in custody “‘ until His Majesty’s 
pleasure shall become known ’’. The usual sequel is an order by 
the Home Secretary for the prisoner to be detained in the criminal 
asylum at Broadmoor. 

The Trial of Lunatics Act, 1883, abolished the old verdict of 
acquittal and substituted a special verdict of guilty but insane 
at the time of the commission of the offence. This special verdict, 
which is a flat contradiction in terms, is now held not to be a 
“conviction of the indictment ’’, but tantamount to acquittal 
of commission of an actual crime. Hence, after such a finding, 
no appeal lies to the Court of Criminal Appeal. 

Suicide.—In the eyes of the law suicide is a felony unless 
the person is found by a coroner’s jury to have been insane at 
the time when he committed the act. By an old Act of Parlia- 
ment the goods of a person found guilty of felo de se may be 
confiscated by the State, but in practice this is nowadays never 
carried out. 

Any person who aids and abets another to commit suicide may 
be guilty of murder. If two persons agree to commit suicide 
together and one fails, the survivor may be guilty of murder. It 
a person, in attempting to commit suicide, occasions the death 
of another he may be guilty of manslaughter. 

Two words of warning by way of conclusion. When a medical 


566 MIND AND ITS DISORDERS 


witness is called upon to give evidence respecting the mental 
condition of an accused person he is allowed a great deal of 
latitude and is expected to give his opinion freely; but he must 
remember that he is in a Court of Law, not in a lecture theatre, 
and he should refrain from wandering into a discourse upon the 
disorder from which the accused is suffering. Should he be asked 
to express an opinion concerning the prisoner’s responsibility, this 
means moral or mental, not legal responsibility. The legal 
responsibility is a matter for the jury to decide. And when he 
examines a prisoner, he should not discuss the crime itself; he 
is there to examine his mentation and it is best to assume the 
attitude that he knows nothing of the crime. Of course, if the 
prisoner introduces this subject, the conditions are changed. 
In any case it is advisable to be provided with writing materials 
so that the prisoner’s own words can be taken down in his 
presence. 


SCHEDULES 507 


53 Vict., c. 5, Sched. 2, Form 1. 


Petition for an Order for Reception of a 


(@ a Justice of 
the Peace for Aire 
His Honour the Judge 
of the County Court of 


(4) Full postal ad- 
dress, and rank, pro- 
Jesston, or occupation. 


(c) At 
one. 


least twenty- 


(Zz) A lunatic, oy an 
diot, ov a person of un- 
sound mind, 


(e) Asylum, ov hospi- 
tal, or house, @s the case 
‘may be. 


(J) Lnsert a full de- 
scription of the name 
and locality of the 
asylum, hospital, or 
licensed house, or the 
Sull name, address, and 
desc: tption of the person 


who ts to take charge of at 


the patient as a single 
patient. 

(2) Sone day within 
14 day's before the date 
of the presentation of the 
petition. 

(h) Here state the con- 
nectton or relationship 
with the patient. 


Private Patient. 


gn the datter of...... 


a person alleged to be of unsound mind. 
AIRC E ee ett on One ve cs eee at on See seshineees danas BOOTS cers: 
GDCRIDCUICION Of..c-eacc0e- asa. sasaedeseestas tess tse eter aee eemeete 
1) Pas eee apres rere eases ss Sanaa’ oanmse ass dal aN neste Meme Beene 


SES ERSTE VEO LM ds gam haw ctvse sae nss ses sdevenemadnn den tememeee dee 


PPA ASINC) a 02> aadyer odes eas sess reese VOals OL age. 


2. I desire to obtain an Order for the Reception 
DURANCE SE OC PISGrEP Ee : 
Wate C) teers 


ee eee eee eeeene 


BULLE aU | cee. access EPR SEY OR CE pais abe ba ao 


eel aioe SAW CHG. SAR Ger css saccades Sek Sen canae RAE Perey Pr : 
SUSU eae aan nesien nd VOL acdsasresea <r exee saattenes ey Arc : 
Ameen (Alors wie sast era: sta ceen ceed: Sie eeee fe oeere Ole cue 
SAN rere ana actaa cLuee sds ony csus pus S0ae cace oe eens vomap ere os tenerrae 


for if the Petitioner is not connected with or 
related to the Patient, state as follows :—] 


I am not related to or connected with the said...............005 


POPSET EHH SHES HHEH HEHEHE EHH HHH HES SSH HHH EHH HEHEHE HHEHR HEHE EHO 


The reasons why this Petition is not presented by a 
relation or connection are as follows: 


568 MIND AND ITS DISORDERS 
The circumstances under which this Petition is pre- 
sented by me are as follows: 


5. I am not related to or connected with either of the 
persons signing the certificates which accompany this 
petition as (where the petitioner is a man) husband, father, 
father-in-law, son, son-in-law, brother, brother-in-law, 
partner, or assistant (or where the petitioner is a woman), 
wife, mother, mother-in-law, daughter, daughter-in-law, 
sister, sister-in-law, partner, or assistant. 


6. I undertake to visit the Said......:.1.:.sssmeeenenee eae 


BE Ee Ory Ae ea Hoty personally, or by someone specially 
appointed by me, at least once in every six months while 
under care and treatment under the Order to be made on 
this Petition. 


7. A Statement of Particulars relating to the said 


a ashes oveescuatdswn's@s qoies cpeaenee ence ase heee ssn | penn accompanies 
this Petition. 


If tt ts the fact, add : 8. The Said.............esessessenee eee 
(@) Asylum, or hos- has been received in the (2).......sse0ceecessensestenesseeea aan 
pital, or house, as the 
case may be. 
under an Urgency Order dated the........:2s.maseseeue seen 


SOOTHE EH ETE EHH EHH HEHE SEH HEHEHE EEE SEE EEE EEE SHEE EESHEEE SHEE HEE EHEE HEE HEE EHEEEE 


The petitioner therefore prays that an Order may be 
made in accordance with the foregoing Statement. 


(24) Full Christian (Signed) (R) 0.6 0:0 066 6 6/e's o/eieluleisielulo'e’ ets efereta/e is eieteteraiata 


and surname. 


COC HHEOHHEHHHHEHHEHET EE HHEHH EEE EEE 


SCHEDULES 569 


53 Vict., c. 5, Sched. 2, Forms 4, 2, 8, and 9g. 


Form of Urgency Order for the Reception of a 
Private Patient, with Medical Certificate and 
Statement accompanying Urgency Order. 


3, the undersigned, being a Person Twenty-one years 
of age, hereby authorize you to receive as a Patient into 


(z) House, or _ hos- your (a) 
pital, or asylum, as a 
single patient. 


(o) Name of patient. (b) 


SOT E HE HHHHHHEHEHEEEHEHHEEHEHHEEHEEHEEEHE SER HEHEHE EHS EEEEH HEE EEE EE CHHHED 


ee 


PME AR AS © 1 (C) ce ses ec owes co ee testasen dees asesnvadscncncaaeses whom I last 
idiot, or oo aoc of un- 
sound min 
SAW CL Us eee woes ey dh ce oh the Woe baler ov oes Cetus ty Secu, > ELT ESRC OONRON NETS eee 
(d) Some day within On the (@)..... SPECS a ye BRRO SIS: Day Of, . vicseccacavanvececs Eons a 


two days before the date 
of the Urder. 


3 am not related to or connected with the Person 
signing the Certificate which accompanies this Order in 


(ec) Husband, wifey any of the ways mentioned in the Margin. (e) Sub- 
father, father-in-law, 


mother, mother-in-law, 

oe PEG ies, joined oy annexed hereto is a Statement of Particulars 
brother, brother-in-law, 

sister, sister-in-law, part- : 5 

ner, oy assistant. Pele RAM EAT CLL OU SAIC ys va ves pases ken ch hessasStnntnamacacgssvessnwemann 


(Signed) 


[Uf not the husband or Name and Christian Name \ 
wife, or a relative of the 


patient, the person sign- at length = — ca a | 
ing to state as briefly es 

osstble: 1. Why the 
ci tality Mgt stoned by rank, Profession, or Occu- \ 
the husband or wife, or RNS FRR ofa nisin spin nperinin at aac 8 ae bain) a'ee aoe see ae 
a velative of the patient. pation (af any) - ={ 
2. His or her connection 
with the patient, and Fy]] Postal Address - Zp sieRvads cob ths vid. oteh Ve neat 
the circumstances under 
which he or she signs.) 


OOOO eH He EHH EEE HEHEHE HEHEHE HEE EEE EEE 


How related to or connected eeeeee eeeeerereeeeeeeereeeeeee eee 
with the Patient - -} en ae 


Dated this....... Ree Abt: or ERE ey. scans Le eee 
(/) ylidueg eset of 
=----s= the ----:- asylum, 
hospital, 7 resident eeeoee eeeeveave eeeeeeeeeneeeeeeeeeeeeeee 
licenseeutthe --. house To Chives ala Wie elole'v s\e'ein slo wis'eiele e'ele'elele 


[describing the asylum, 
hospital, or house by 
situation and name}. Pietra see's gO LIOR E. Ss BORER CPT REE EO STEELE pence 


570 MIND AND ITS DISORDERS 


Form 2. 


Statement of Particulars referred to in the 
annexed Petition. 
If any Particulars ave not known, the Fact is to be so stated. 


[Where the patient is in the Petition described as an idiot, omit the 
particulars marked*.]} 


The following is a Statement of Particulars relating to the said.................. 
Name of Patient, with Christian Name at length..............0e,seseeeeepeeee een 
Sex and Age - - - - - - ~ sacdcoscegecesneneeee as <eea 


*Married, Single, or Widowed - - - scan #'n d.psecocs ee 9:0 eipsie tale eels ee tn 


*Rank, Profession, or previous occupation (if) 


any) e Ex 2 me = 2 me tee eee eww eee eeeeeeeeseeeeaee 
* Religious Persuasion - - - - — nen osecdocueuas eka eae sey enema 
’ Residence at or immediately previous to the 
dence at of immediately previous tothe\ 1a 
*Whether First Attack - - - - ~ cccccetsevcesnncdaualtn tanya 
Age on First Attack - - - . ~ ivvccnsocenedag hesieegns agama 
When and where previously under Care amd) ..........csccccccceccccessssnsusees 
Treatment as a Lunatic, Idiot, or Person 
of Unsound Mind - - - ~ @ | sccesesenssuetasanap enema 
*Duration of Existing Attack - ~ - m Selvo sd deena cemnt gaeees eRe ean 
Supposed Cause - a: - - SPT or 
Whether subject to Epilepsy - - - = lecececsec canes siltiee ey eee ee 7a teame 
Whether Suicidal - - - - - ~ scncoceseccancticcdtese} i= ieemeean 
Whether Dangerous to Others, and in what way..........:....ssscesscsssssuessssee 
Whether any near Relative has been afflicted 
che; any near Kelative has Deen ailicted| | 
Names, Christian Names, and full Postal Ad-) ............:cccccseecescnnsavccvoss 
dresses of one or more Relatives of the 
Patient - - - - - - SD PTT eC 
Name of the Person to whom Notice of Death) ...........cccececsceccecsencccevees 
to be sent, and full Postal Address, if not 
already given - - - - - - J a co-ceanaieaia ts aaisiemin irda ceteare ae aam 


eee eee eee eee ee See SHES SHHEHEEE 


tName and full Postal Address of the usual 
Medical Attendant of the Patient’ - . 


(SIGNED) ccseescvvevewecviccecssersnsensattauneces cose> aa sneeunaanayRaaaEnyEEs 
A Similar Statement must also accompany an Urgency Order. 


+ Not required in pauper cases or for lunatics wandering at large. 


SCHEDULES 571 


When the Petitioner or person signing an Urgency Order is Not the 
person who signs the Statement, add the following particulars concerning 
the person who signs the Statement: 


Name, with Christian name at length - - 


SSeS e sere eee eeeeseseereresesesere 


Rank, profession, or occupation (if any) - 


COCO eee rete se eee eee eres Eeeeeeseoes 


How related to or otherwise connected with) 
the patient 3 i z i 5 By RTs aR eSectd: 


BSeVict. oCa5,.S-)31: 


When neither Certificate is signed by the usual 
Medical Attendant.* 


J, the undersigned, hereby state that it is not practicable 
to obtain a Certificate from the usual Medical Attendant 


a) Name of patient. of (a) 


SHOTS HHSHOHSHOSHOSHHHOHSHOEH OHH CES OHH HOH LOE COCR OCHREEHEECO RACES OROCEH CCE CESCES 


for the following reasons, viz.: 


5) To be signed b { 
a Rpt eas asad CSSTQIICO]g (O) an caren case se oocpeusenncs cnccevecsereemes 


53 Vict., c. 5, Sched. 2, Form 8. 


SE ITLIOMINSALLOLEOL erate ret chca cc tee crocs esau eer estates cc ces eae ies 
Pe ME hea oc os (cade rs cass ge case Gennse sbeyuedeesdissonseivetteges 
patient. 
(5) County, city, or : 
borough, ef ee case 1N the (b) cece e reece csccccccccccescceces Si bee inet, pies ewian ateee cet eee 
may be. 
eae a IT REE MN os oo 0s Sn va fuekeds eons causie¥s siucbesen is cdthsaieens teen 


or occupation, tf any. > 
an alleged lunatic. 


PR MCUIMBUUCCESIONOC Foie. conarogscasnctestsuscuscassssccscnawescedeteers 
do hereby certify as follows: 
1.I am a person registered under the Medical Act, 


1858, and I am in the actual practice of the medical 
profession. 


* Not required for pauper cases, for lunatics wandering at large or for those 
not under proper care and control or being cruelly treated or neglected. 
{ Insert name in full. 


572 MIND AND ITS DISORDERS 


(d) Insert the place of 2. On the 


bphination, ohing he At Te Re eee eee eee day Of...02. seen ase cope en 

name of the street, with 

nmuniber or name of at (a) Coe recon eeececcceeneceeeeececce eoecee Core ore ccrcereceseereeeenesseseess 

house, or should there , 

be no number, the Chris- In the (e) evel eV overs, sveiets oleiore (eleuntecsts eerie Of...) eee ai eia aiohelalele ste 6 0 ces nes aemem 

tian and surname of 

occupier, : : 

(6) County, city, or I personally examined the said........ foe woos 00s Dee 
orough, as the case . 

ay be and came to the conclusion that he is (f)....... sé ds. 
(7) A lunatic, an idiot, 


or a person of unsound and a proper person to be taken charge of and detained 
mind, 
under care and treatment. 


3. I formed this conclusion on the following grounds, 
Vales 


(a) Facts indicating Insanity observed by myself at 


(g) If the same or the time of examination (g), Viz.: ........s.s0- snes, Ce EP 
other facts were obse ved i 
previous to the tinte of 
the examination, the (°c cess eerseccccvccccscccccssceesscecece © 6 s:wie wie. Sata. elw ale nfatateye ecccvccecces 
certifier ts at liberty to 
SUOJOCH CHEM TI ASEPAT SE a 0/0 3.4\0n:0\01050\0 5) \oue 6610/0) 4 61s 0 014.8 c)e le blen's eiclciels wba ae ee cccscccce eee erceeseee 
ate paragraph. 


(4) The names ana (6) Facts communicated by others (h),viz.: ......csceceeeeees 


Christian names (t, 
known) of informants 


to be given with thetr e@eereeeereeeeeee eereeeeeser eee eee eee eee eee eee eene eeeeeeeeee eereereeeeee . . eeereee 
“ , 5 
addresses and descrip- 
LLORES FI PO ia c'0'0, 6.00.0. 0 010.0 08)e-0.5\ 8 68m wi ecsle m vehi ere'ankiniueplare Siptaiare’e seer cee Peewee eee rereeesssene 
eeoereeeeeeeeeeeeeseeeeseeeeseseee ieee eee ee ee ee ee ee 2 | 


PHCHHCHCOHCEH SS HOCHOHSEH EKA EHEEHOHS OLEH EES OHO SLEHKE CO OSOSCEEEESEEE SESH ESS 


(2) If arn wurgercy cer- it is . 
ns Ya ER s 3 certify that it is expedient for the welfare of the 
t be added here. J 
Form Wvea, Bald cavcaccsveds cee Meee nts vote RE RAS ce ...[or for the public 


safety, as the case may be] that the Saids............-.sesseeeee 
should be forthwith placed under care and treatment. 


eee eee eeeeee 
ee a] ee eeeeee eee eeee ee | serene 
. . . . . . eeee . ereee eres ee 
eeeee SHOCHSHHSSOH HOCH SHH SHEHOAOHAHOSSCHOHE SHO HCO ROTH OHE HOCH OSES ESCO DESCELOERHaCSOS EUS SNE 
eee eee reene ee POSSCHH HSE SHCHCE HOC ETOCCE OOS OLE COCCC OE DSE DS © SOG 8 0666 6s Us 664 Siale a een 
SOT HHHHHHHHEHHEHEHE EHH ET EEE HET H OHHH EEE HEE EES eeeeeee Seer e eee seers eeeeeseeseeee 
eeeee COHH HEHEHE HEHEHE HEHEHE HECHT ESC EEO EEE EHS EH OEE EES OEE OEE SEE SELES E LEE OOO 


AL ne sSalduine, av: crease csacggeas Coen 
(2) Strcke out this appeared to me to be [or not to be] in a fit condition of 


clause in case of 


brivaté patient whose re- Hodily ‘health tobe removed to°an asylum: hospital, or 
moval ts not proposed. ; 
licensed house (A). 


eeeeree ee ee | 


(¢) Insert full posta 
address. 


SCHEDULES 573 


5. I give this certificate having first read the section of 
the Act of Parliament printed below. 


SD AUC OD CNIS semana tae heen onesn at, day of 


One thousand nine hundred and 


ey 


(SIGNED)... ereereeeeeeceeeeteeeteeeeeeeeeeeeeeeeeees 


ee 


Extract from Section 317 of the Lunacy Act, 1890. 


Any person who makes a wilful misstatement of any material fact in 
any medical or other certificate, or in any statement or report of bodily or 
mental condition under this Act, shall be guilty of a misdemeanour. 


Raewice Ges. Sched. 2, form: 3. 


Order for Reception of a Private Patient. 
To be made by a Justice appointed under the Lunacy Act, 1890, Judge of 


(az) A Justice for:------ 
specially appointed un- 
der the Lunacy Act, 
1890 ; ov the. Judge of the 
County Court of ------- . 
or the Stipendiary 
Magistrate for -------. 


(6) Address and occi- 
tation. 


(c) Or an idiot or per- 
son of unsound mind. 


(d) Name of petitioner. 


County Courts, or Stipendiary Magistrate. 


J, the undersigned...........ceceeesesceceeeerereneeeeeeeeneneeeeeeees 
DPS (ly ee eae ca tees Wan ou Sapo ap tne qncnwannenvosnctans feesecsacetns 


Ca MAC eC eC a see Cale Rw De eS 0 © Oem wee Bee sae 50 F'9 SU #10810, 8) 2 o 6/0 M06 Os .0:9'8i8 12 (8008.2 ® SiS Se 


PM LEATIC. (Chcsccccces cst encasacnes este ceen accompanied by the 


Medical Certificates Of.......scscecvesscececcesseeeeceecssececcessenes 


hereto annexed, and upon the undertaking of the said 


TD etste hte a. eds pa teac tere rsewesdeenco ners asnee Meens to visit the 


574 MIND AND ITS DISORDERS 


once at least in every six months while under care and 
treatment, under this Order hereby authorize you to 


receive the Said 1.5..0...c.sccccecceneese eee ee penne 


(e) Asylum, or hos- r : 
pital, or house, 07 asa AS A Patient into your (e) 0.006 0.8:6 wie w\nia'is @)9) 6: o's\e.¥e wm aletare a tatetet ner ana re a ievlie tl 


single patient. : 
And F declare that I have [ov have not] personally 
seen 4 the Said snvecce ee ee eee ee ts eas cons omegniee sai eta 


before making this Order. 
DMATCOT MIS. ce ee tee day of....i03) ee tO... 


(GIGNCD) (@)..002...s0000+000000ee-ces sheen 


justice for..c:Apee eee appointed 

under the above-mentioned Act 

[or the Judge of the County 

Court Of....seseensesn eee 

(/) To be addressed to or a Stipendiary Magistrate]. 


the medical superinten- 

dent of the asylum or 

hospttal, or to the resi- 

dent licensee of the house To (f) O06 0.910056 0.0 0 60.0056 00 8.0ce weiss selene 636.66 sle/s © atule oiniela Minty a myetals elaine ene 
tu which the patient ts 

to be placed. 


53 Vict, c. 5,18. 7.(4ke 
When a Previous Petition has been dismissed. 


3, the undersigned, hereby state that a former Petition 


(z) Nameof patient. for the Reception of (a).....0.:+-s-..<ssesssanieee eee en 


(2) Name of asylum, j 
hospital, licensed house into () 
or single charge. 


eet OOO OOOH HHO eee Oe eee HHO HHT HEHE HEHEHE THEE EEE EHH HE THETHEE HE EE EEE ETE EES 


Was preSemted 0.....056. 020066 ecseceoceessn cee 
(c) Justice of the Peace (c) 
me ee or Judge of (C)erseteeeseeeceseeececscecseessseseeeceseeesesnessesesnsececeseseseseeeeuss 
County Court Of eae roe : , 
or Stipendiary Magis- nthe Month Olea. cesaes creas eee eee 5» Lee , and dismissed. 
rate for -.--.- 4 


Herewith is a copy (furnished by the Commissioners in 
Lunacy) of the Statement sent to them of the reasons for 


its dismissal. 


(GIGNCO) ..ccse02.0ncscons ence esecendeselenne enter tenement 


The Schedules for sending a mentally defective person to an institution 
or certified house for mentally defectives or for placing him under guardian- 
ship are very similar to those of the Lunacy Acts. When required, the forms 
can be obtained from Shaw and Sons, Fetter Lane, London, E.C. 4. 


. 


APPENDIX A. 
METHODS OF STAINING THE NERVOUS SYSTEM. 


For all ordinary purposes the following methods of making 
microscopic preparations of the nervous system will be found 
sufficient. 

Pieces of tissue requiring examination should be not more than 
% to I centimetre in thickness and should be hardened as a rule 
in a 10 per cent. solution of formalin, formalin being a 40 per 
cent. solution of formaldehyde. The specimens are ready for 
further treatment in about ten days. 

To prepare them for the microtome they should be washed for 
twelve hours in running water, placed in methylated spirit for 
twenty-four hours, then in absolute alcohol and ether (equal 
parts) for twenty-four hours. They are then ready for em- 
bedding in photoxylin, a substance closely related to celloidin. 

They should first be placed in thin photoxylin solution (1) and 
then transferred to a thick solution (2) of syrupy consistence: 


iijmehotoxyln’ ... ve se mee ail 
Absolute alcohol... by cee taxlts 
Ether om a a San Se atk 

(2) Photoxylin.. ae Ye eho Iv 
Absolute alcohol ar re me Ae 
Pier .s. oy nee te al 


They are mounted on pieces of wood about # inch cubical. 
The piece of tissue is taken on a section lifter out of the second 
photoxylin jar and placed on a piece of wood, with plenty of the 
photoxylin solution round it. There it remains for a variable 
time, about a quarter of an hour in moderately warm weather, 
until the photoxylin becomes of the consistence of a firm jelly. 
The specimen is labelled by writing in pencil on the wood and 
the whole thing then dropped into a jar of methylated spirit to 
await section. 

D772 


576 MIND AND ITS DISORDERS 


Any microtome may be used. The author is accustomed to 
use Schanze’s instrument. 

As the sections are cut they are transferred to a pot of methy- 
lated spirit. 


Nissvc’s METHOD OF STAINING NERVE-CELLS. 


The sections are placed on the surface of some Griibler’s. 
solution of polychromatic methylene-blue in a watch-glass, which 
is then warmed over a flame until steam appears. They are 
removed by means of a needle and placed in a basin of water, 
washed and transferred on a section lifter to methylated spirit, 
which dissolves out much of the methylene-blue. They are 
then passed through absolute alcohol, where they remain until 
differentiation is complete, into aniline oil which stops the 
process. Some pathologists, instead of using the absolute 
alcohol and aniline oil. separately, leave the sections for some 
hours in a mixture of the two (equal parts). 

The sections are then passed through oil of origanum into 
benzene, in which they may remain for any length of time. They 
are finally mounted in colophonium resin dissolved in benzene, 
which may be lighted and partly burnt off before applying the 
cover-glass. 


Cox’s METHOD OF OBTAINING A SILHOUETTE OF NERVE-CELLS 
AND THEIR PROCESSES. 


At the autopsy pieces of fresh tissue are washed free from 
blood and placed in the following: 


5 per cent. solution of perchloride of 


mercury me 20 parts 
5 per cent. solution of alone potassium 

chromate a es Es . toe 
Distilled water .. 40 ,, 
5 per cent. solution of potasciuen bi- 

chromate ~ a ae .. 200s 


The bichromate solution should be added last. 

The pieces are transferred next day to fresh solution and 
are ready for cutting in three months. They should not be cut 
too thin. 

The nerve-cells and their processes appear black against a 
white background. 


METHODS OF STAINING 577 


STAINS FOR TRACT DEGENERATION. 


If the tract degeneration is recent, one to six weeks old, 
advantage is taken of the fact that, while the phosphorized 
fat of medullary sheaths does not stain with osmic acid, the 
dephosphorized fat of degenerating medullary sheaths does. 

The pieces of nerve tissue to be examined are best fixed in 
Miiller’s fluid, which consists of: 


Potassium bichromate .. sf Pa. 62) parts 
Sodium sulphate .. a an emeels Done 
Distilled water .. ne fs -. 100 parts; 


but it does not matter if they have been in formalin first. 
They are placed for about a fortnight in Marchi’s fluid: 


I per cent. solution of osmic acid .. 1 part 
2 per cent. solution of potassium bi- 
chromate .. ats Pe 2 parts: 


washed in running water for twenty-four hours and hardened in 
alcohol. They are then mounted in photoxylin, as described 
‘above, and cut. The sections should not be too thin. The 
degenerated myelin sheaths appear black. 

If the tract degeneration is of long standing, the following 
method of staining the myelin sheaths may be employed (Weigert- 
Pal). 

The sections are cut and lie in methylated spirit. They should 
be treated separately. 

They are first stained for twenty-four hours in Kultschitzky’s 
hematoxylin: 


Hematoxylin .. oe ie .. 2 grammes 
Absolute alcohol ey .. Enough to dissolve 
Acetic acid (2 per cent. solution) .. I00C.c. 


This is at its best when it is some months old. 

The sections are washed in distilled water and placed in 
Miiller’s fluid for two minutes, washed again and placed in a 
solution of potassium permanganate (75 grammes to I pint) 
until the grey matter is of a yellow tint (usually about one 
minute). They are again washed and then transferred to Pal’s 
solution: 


Pure oxalic acid .. ay ae Peeeuleo lame 
Potassium sulphite 1: : igh 
Distilled water .. - + eas 200.C.C; 


SY; 


578 MIND AND ITS DISORDERS 


If the differentiation is not complete, the sections should be 
washed and the whoje process repeated from the potassium 
permanganate. 

The sections are now placed in a strong solution of lithium 
carbonate for a quarter of an hour and once more washed. | 

They may be counterstained with picrocarmine. 

Dehydrate in 


Xylol re eae 3 parts 
Absolute phenol .. Di ig i! opare 


and mount in Canada balsam. 
The degenerated tracts appear pale against a blue back- 
ground, the undegenerated myelin sheaths being stained blue. 


STAIN FOR AXIS CYLINDERS. 


There is at present no very satisfactory stain for axis cylinders, 
but the following method (Freud’s) may be tried: 

Fresh pieces are hardened, preferably in the dark, in Miller’s 
fluid, washed, further hardened in rectified spirit, embedded in 
photoxylin and cut. The sections are steeped for about four 
hours in 


Gold chloride solution (1 per cent.) 


Alcohol (95 per cent.) \ equal parts. 


They are then washed and placed for three minutes in 


Saturated solution of sodium hydrate .. I part 
Distilled water... ae ff o+ ld tes 


They are again rinsed and steeped for about ten minutes in a 
Io per cent. solution of potassium iodide. At this stage they 
assume a reddish-violet colour. They are now washed, cleared 
in methylated spirit, absolute alcohol and xylol and mounted in 
Canada balsam. 

Metal instruments must be avoided and glass ones ssed 
instead. 

WEIGERT’S STAIN FOR NEUROGLIA. 


The pieces are hardened and mordanted in the following fluid 
for ten days: 


Chrome alum sy 7 a .. 24 grammes 
Copper acetate .. cag 3 es ny 
Acetic acid is fp te ae op ve 
Formalin .. mae ue <' ve Ate 


Distilled water ,. oo $2 ho 90 


METHODS OF STAINING 579 


Boil the chrome alum in 80 c.c. of water. Turn out the Bunsen 
and add the acetic acid, then stir in the copper acetate while the 
mixture is still hot. Filter when cold, then add the formalin and 
the rest of the water. 

It does not matter if the tissue has previously been hardened 
in formalin. Sections are made by the photoxylin method. 

From spirit the sections are transferred to water, then to a 
I in 300 solution of potassium permanganate for ten minutes. 

They are washed and placed in the following reducing solution: 


Chromogen i a Me .. 5 grammes 
Formic acid es Ay - SE HONE 

Io per cent. solution of sodium sulphite 10 c.c. 
Distilled water .. i ire Le ee Nedes 


The sodium sulphite is added immediately before using the 
solution. 

When the brown sections have been decolorized they are 
twice thoroughly rinsed and placed in a 5 per cent. aqueous 
solution of chromogen for a few minutes. 

They may then be counterstained, preferably on the slide, 
with 


Saturated solution of picric acid ee LO, G.Gr 
I per cent. solution of soda-carmine .. 2 C.C. 
Absolute alcohol .. ~ me ae, Aa ees 


The section is now blotted and a saturated solution of methyl 
violet in rectified spirit dropped on it. This solution must be 
prepared with hot alcohol and be filtered after cooling. The 
section stains almost instantaneously. 

The superfluous methyl violet is blotted up and a saturated 
solution of iodine in a 5 per cent. solution of potassium todide 
dropped on the specimen and immediately poured off. The 
specimen is then thoroughly washed in aniline-xylol (equal 
parts), then in pure xylol and finally mounted in Canada balsam. 


APPENDIX B. 
EXAMINATION OF THE CEREBRO-SPINAL FLUID. 


AN examination of the cerebro-spinal fluid is sometimes of 
assistance in the diagnosis of disease. In the department of 
medicine which forms the subject of this book such an examina- 
tion is especially useful as an aid to diagnosis in doubtful cases 
of general paralysis. 

Lumbar Puneture.—A specimen of the fluid may be obtained 
during life and without injury to the nervous system by means of 
a hollow needle passed into the spinal canal, preferably between 
the fourth and fifth lumbar spines. This may be done while 
the patient lies in bed on his side, but it is much better if he sits 
on a low stool, stoops forward and dangles his arms between his 
knees, the finger-tips resting on the floor. This position tends 
to separate the lumbar spines from one another. 

The requisite apparatus consists of a test-tube, a hollow needle 
made of platinum or iridium so that it will not snap and may 
be boiled without rusting, a stilette of the same metal and an 
all-glass syringe or a suitable piece of metal to fit the end of 
the needle and serve as a handle. These should all have been 
sterilized by heat and the patient’s skin over the fourth and fifth 
lumbar spines cleaned and painted with iodine liniment. 

Now a straight line drawn across the back at the level of the 
highest point of the iliac crest passes over the fourth lumbar 
spine. The needle should therefore be entered immediately 
below this. 

The operator places his left forefinger over the fourth lumbar 
spine to serve as a guide and enters the needle in the middle 
line in the space immediately below. The needle is pushed 
horizontally forward for a distance of 3} inches (in an adult). 
Should the operator strike bone, the needle must be slightly 
withdrawn and pushed in a little higher or lower, as the case 
may be. When the handle or syringe is removed the fluid 
drops from the end of the needle. If this does not happen the 
lumen of the needle should be cleared by means of the stilette. 

The first few drops are allowed to escape since they are liable 


to be contaminated with blood; then about 5 to 8 c.c. are collected 
580 


THE CEREBRO-SPINAL FLUID 581 


in the test-tube. This is closed with a piece of sterilized wool and 
the wound sealed with collodion. 

The intraspinal pressure can be judged sufficiently for practical 
purposes by observing the force of the stream from the puncture 
needle. If the fluid runs with a strong stream more or less like 
the flow of urine in micturition, the pressure is high; if it falls 
in a continuous stream almost vertically from the end of the 
needle the pressure is moderate; if it falls in an interrupted 
stream or in drops, the pressure is low. For more accurate 
investigations a Landon manometer may be used. Readings 
above 12 mm. should be regarded with suspicion; those above 
20 mm. are undoubtedly pathological. The pressure is increased 
especially in general paralysis, meningitis, cerebral and spinal 
tumours and hydrocephalus. 

Preparation of Specimens for Cytological Examination.—The 
most practical method is that of Fuchs and Rosenthal, who have 
invented a slide somewhat similar to the Thoma-Zeiss slide but 
with larger divisions and twice the depth.* Unna’s polychrome 
methylene-blue is drawn up to the 0:5 mark of a white corpuscle 
pipette and cerebro-spinal fluid up to the rz mark. Fluid and 
stain are shaken together for four or five minutes. The first two 
or three drops from the pipette are rejected and the mixture is 
then allowed to flow over the slide and to settle for at least five 
minutes. The quantity of fluid should be insufficient to flow 
over into the moat. The rulings are 4 mm. square and the depth 
of the fluid is 0-2 mm. The number of cells is counted in 16 sets 
of 16 squares and the result multiplied by 21 and divided by 64. 
This gives the number of cells per c.mm. A differential count 
may also be made. 

Henderson gives the following standards as satisfactory: 


Less than 5 cells per c.mm. - .. negative 
From 5 to 10 mf ae zt .. doubtful 
pbove 10. = gh a .. pleocytosis 


Alzheimer’s method is as follows: 

Absolute alcohol is added to the fluid in the proportion of 
one to two, and the whole well shaken to ensure thorough mixture. 
This coagulates the albuminous constituents. 

The mixture is placed in the electric centrifuge for one hour. 
This drives to the bottom of the test-tube the particles of coagu- 

* The slide is made in solid glass, so as to do away with any error 


resulting from contraction of Canada balsam, by Messrs. Hawksley and 
Son, 357, Oxford Street, London, Wt: 


582 MIND AND ITS DISORDERS 


lated albumin with any cellular constituents and welds them 
into a little solid mass. 

The supernatant fluid is poured off and the mass is hardened 
by treating it with absolute alcohol for one hour. 

It is now treated with alcohol and ether (equal parts), then 
with ether (one hour each), loosened from the bottom of the 
test-tube with a fine platinum needle and gently shaken into © 
thin photoxylin in which it remains for twelve hours or more. 
It is then transferred to thick photoxylin and mounted on a block 
of wood as described in Appendix A. 

Sections are made of a thickness of 14p and stained for about 
six minutes in the following solution (Pappenheim’s pyronin 
methyl green) in the incubator: 


Methyl green oe se ~ *.- “Or Seeante 
Pyronin =. Ay a .. "O25 aaee 
Alcohol (96 per cent. | etc s/ 2 see 
Carbolic acid (5 per cent.) 45 .. YOOuEe 


The sections are immediately transferred to a basin of cold 
water to remove superfluous stain and placed in absolute alcohol 
until the colour ceases to come away. 

Lastly they are cleared in xylol or oil of cloves and mounted 
in Canada balsam. 

So far as I am aware, there is no reason why pyronin-methyl 
green should not be used in the Fuchs and Rosenthal method. 
It would give a differential stain, but I have not tried it. 

Cytological Examination.—The microscopical appearance of 
a specimen prepared in the above manner is shown in Fig. 72. 
Nuclei are stained blue and protoplasm pink. 

Lymphocytes.—These are nearly all nucleus with a “ clock- 
face ’’ arrangement of chromophilic granules. 

Endothelial Cells—The nucleus is “ horse-shoe’”’ shaped or 
oval and eccentric in position. There are very few or no 
chromophile granules. The nucleus does not stain quite so 
deeply as that of lymphocytes. They are sometimes phago- 
cytic, as seen in the cell marked “ phagocyte ”’ in Fig. 72. 

Plasma Cells.—The nucleus is eccentric in position and has a 
well-marked “ clock-face ’’ arrangement of chromophile granules. 
The protoplasm stains more deeply at the periphery than | near 
the nucleus. 

Polymorphonuclear Leucocytes.—The appearance of these is too 
well known to require description. The nucleus is of charac- 


THE CEREBRO-SPINAL FLUID 583 


teristic shape and the protoplasm is not stained by the above 
method. 

In normal fluid one may expect to find five to fifteen cells in a 
hundred fields, lymphocytes and endothelial cells only. 

In general paralysis all the above forms are common and 
plasma cells rarely occur in any other disease. In Alzheimer 
sections there may be 200 to 1,000 or more cells in roo fields, 
but the characteristic feature is the high percentage of lympho- 
cytes (over 60 per cent. in 80 per cent. of cases and over 70 
per cent. in 70 per cent. of cases). The cell-count is for some 
unknown reason much higher when the fluid is obtained post 
mortem. 

Globulin Reaction.—The Nonne-Apelt is by far the most 
satisfactory test. Equal parts of cerebro-spinal fluid and a 
saturated solution of ammonium sulphate are shaken together 
in a test-tube. If a cloudiness appears within three minutes 
the quantity of globulin is excessive and a positive reaction of 
this nature is a strong argument in favour of the diagnosis of 
general paralysis. 

Other tests for globulin are the formation of a nitric acid 
ring, as in testing urine for albuminuria; formation of a cloudy 
ring with a saturated solution of ammonium sulphate (Ross- 
Jones) and the formation of a flocculent precipitate on boiling 
2 c.c. of cerebro-spinal fluid with 5 c.c. of a Io per cent. 
solution of butyric acid in physiological salt solution and then 
boiling this with a I c.c. of normal sodium hydrate solution 
(Noguchi). 

The Gold-Sol Test for General Paralysis.—This is a kind of 
quantitative test for globulin, which is based upon the observa- 
tions that (1) protein solutions will precipitate colloidal gold in 
the absence of an electrolyte (such as sodium chloride), (2) an 
electrolyte will in certain concentrations precipitate colloidal 
gold and (3) there is a minimal precipitation of proteins and 
colloidal gold when in the same mixture a 0-4 per cent. solution 
of sodium chloride is used. 

Preparation of the Colloidal Gold Solution.—All the glass 
apparatus (including thermometers) used must be rendered 
chemically clean by boiling in bichromate cleaner for half an hour, 
washed in tap water and ultimately in water triply distilled in 
an apparatus with no rubber connections. All solutions used 
must be in such triply distilled water. 

Heat over a Bunsen burner 1,000 c.c. of this triply distilled 
water in a beaker, with a thermometer. 


584 MIND AND ITS DISORDERS 


At 60° C. add 10 c.c. of a I per cent. solution of gold chloride 
crystals and 7 c.c. of a 2 per cent. solution of pure K,CO,. 

At 80° C., while stirring, add 10 drops of a 1 per cent. solution 
of pure oxalic acid. 

At go° C. remove the burner and, while stirring, add 5 c.c. of a 
1 in 40 solution of pure formaldehyde, 7.e., till a pinkish tinge 
begins to appear. 

Subsequently the resulting fluid becomes orange to salmon-red. — 
It should be perfectly clear and neutral in reaction, giving a 
brownish-red coloration with a 1 per cent. solution of alizarin-red 
in 50 per cent. alcohol. If it is not neutral it should be rendered 
so by a drop or two of 1 in 50 NaHO, or I in 50 HCl (by weight), 
as the case may be. | 

The Test.—Arrange 11 test-tubes (chemically clean like all the 
other apparatus) in a row. Put into the first tube 1°8 c.c. and 
into each of the others 1 c.c. of fresh sterile NaCl solution (0-4 per 
cents): 

Add to the first tube 0-2 c.c. of the cerebro-spinal fluid to be 
examined and mix (of course there should be no blood in it). 
Transfer 1 c.c. from the first to the second tube and mix. Transfer 
t c.c. from the second to the third tube and mix; and so on to the 
tenth. The eleventh is the control and contains no cerebro- 
spinal fluid. Add to each of the eleven tubes 5 c.c. of the colloidal 
gold solution ; mix and set aside for the night. 

The Reaction.—The readings are recorded next day according 
to the following scheme: 


5=complete decolorization (like water) 
4=pale blue 

3=blue 

2=violet or purple 

1=bluish-red 

o==no change 


Normal cerebro-spinal fluid produces no change or perhaps a 
No. 1 change in the first tube only. 

In general paralysis a typical reaction is at least 5555422110. 
An undoubted case may give 5555554211. 

A somewhat similar result occurs in disseminated sclerosis, 
but the decolorization and precipitation in the earlier tubes 
are not quite so complete. 

In tabes decolorization occurs in the early middle (“ luetic ’’) 
zone, for example—4445543100. 


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THE CEREBRO-SPINAL FLUID 585 


This difference between the general paralytic and_tabetic 
reactions is helpful in those cases in which a diagnosis has to be 
made between general paralysis and tabes plus a functional 
mental disorder. 

In cerebral arteriopathy from syphilitic endarteritis the reaction 
is rather like that of general paralysis but much weaker, such as 
4331100000. 

The test is primarily intended for general paralysis; for other 
conditions it is rather unreliable. A sound summary of the 
situation is given by J. Cruickshank in vol. i., part i, of the 
Journal of Experimental Pathology (1920). 

Wassermann Reaction.—The cerebro-spinal fluid may also 
be tested for the Wassermann reaction. A positive reaction 
probably means general paralysis, but opinions are still divided 
on this point; it must certainly be regarded as very strong 
evidence in favour of the diagnosis of general paralysis in those 
cases in which the test is made for the purpose of deciding whether 
the patient is or is not suffering from general paralysis. 

The test is exceedingly technical and should always be left to 
a pathologist who is familiar with the technique. For details 
the reader is referred to ‘‘ The? Wassermann Reaction’ by 
J. W. Marchildon (Kimpton). 


INDEX 


A 
ABDOMINAL sensations, 128 
Abnormalities of action, 152 
general, 218 


Abstinence symptoms (cocaine), 380 | 


» x (morphia), 377 
Acceleration of thought, 141 
Achromatoplasm, 5 
Acne vulgaris, 528 
Acrophobia, 239 
Action, disorders of, 152 

»,  warieties of, 65 
Actions of imbeciles, 497 
Activity, pressure of, 155 
Acute confusional insanity, 388 

», delirious mania, 292, 295 

Addison’s disease, 428 
Adenoma sebaceum, 530 
Adrenalemia, 240, 490 
‘Esthetic sentiments, 104 
Affection, 54 
Agitated melancholia, 273 
Agnostic apraxia, 152, 392 

a perseveration, 126 
Agoraphobia, 239, 256 
Alcoholic dementia, 416 
insanities, 399 
paranoia, 415 

ye seudoparesis, 411 
Aicohniers B72 z : 
Alzheimer’s disease, 481 

- staining, 581 

Amaurotic family idiots, 501 
Amentia, 492 
Amnesia, I41 
Amylene hydrate, 278, 545 
Anesthesia, systematized, 126 
Anal erotism, 183 
Analgesia, 118, 290, 299, 321, 390 
Anergic stupor, 295 
Anomalies of the eyes, 216 
Anterograde amnesia, I41 
Antics, 327 
Anxietas presenilis, 275 
Anxiety hysteria, 238 

A neurosis, 219 
Aphonia, hysterical, 238 
Apoplectiform attacks, 434 
Apraxia, 152, 159, 482 


a) 


39 


| Aprosexia, 163 


| Arteriopathic dementia, 473 
| Articular space-perception, 40 
| Association centres, 10 

ns of ideas, 47 
Asylum, dysentery, 524 

» plthisigszs 

Atavistic abnormalities, 212 
Atropine poisoning, 386 
Attention, disorders of, 163 
laws of, 86 
eo varieties of, 88 
| Auditory sensation, 24 
| 5 space-perception, 41 
Automatic action, 80 

ss obedience, 158, 324, 336 
Automatism, epileptic, 361 
Axons, 5, 6 
Aztec idiots, 502 


+”) 


B 
Babinski’s conception of hysteria, 


230 
| Bath (douche and needle), 545 
», prolonged, 545 
| Bed treatment, 276, 293, 540 
| Belief, 106 
Belladonna poisoning, 386 
Bestiality, 197 
Binet-Simon tests, 505 
Binocular vision, 33 
| Blind-spot, 22 
| Blood-pressure, 208, 320 
Blushing, 256 
Borderland cases, 308 


C 


_ Changed personalities, 172 
Chloralamide, 547 
Chloral delirium tremens, 407 
,- sHydrate, S47 
| Chloralism, 388 
Chorea, 484 
,,  Huntington’s, 485 
_ Chromatolysis, 410, 460 
Chromatoplasm, 5 
Chronic alcoholism, 372 
cortical atrophy, 473 


»”» 


586 


INDEX 


Chronic hallucinatory insanity, 413 
3) «6MaATa, 292 
»,  sulphonal poisoning, 384 
Civilization and insanity, 206 
Civil responsibilities of the insane, 
560 
Clang-tint, 25 
Claustrophobia, 239, 256 
Cocaine paranoia, 382 
Cocainism, 381 
Cognition, 49 
Cold, hallucinations of, 133 
», spots, 26 
Collaterals, 7 
Colonies, epileptic, 371 
Colour vision, 65 
Combined insanities, 515 
Commission, Lunacy, 550 
Communicated insanity, 314 
Complementary colours, 33 
Complexes, 53, 180 
Complex hallucinations of hearing, 


130 
a = of vision, 
131 
Comprehensiveness of mental dis- 
order, 174 
Conception, 43 
Conduct, 65 
fs. disorders of, 152 


Cones of retina, 21 
Confusion, epileptic, 360 
Confusional insanity, 388 
Congenital deformities, 211 
Contraband of lunacy, 540 
Contracts with the insane, 560 
Contracture, 94 

¥ hysterical, 237 
Contrasts, gustatory, 27 

Hi olfactory, 27 

A simultaneous and 

cessive (colour), 23 

Convalescence, 549 
Conversion hysteria, 233 
Convulsions in epilepsy, 355 

in general paralysis, 446 

F in hysteria, 235 
Coprolalia, 337 
Coprophobia, 257 
Cortico-rubro-spinal system, 61 
Cox’s stain, 576 
Cranial anomalies, 211 
Cranks, 307 
Cretinism, 420 
Criminal responsibility, 561 
Cry, epileptic, 356 
Crystallophobia, 256 
Cunnilingus, 196 
Cutaneous affections, 218, 264 
anesthesia, 118 
analgesia, 118 


suc- 


a? 


a” 


587 
Cutaneous sensation, 25 
ne Space-perception, 39 
re stigmata, 218 


Cytological examination, 582 


D 
Deformities of head, pinna, etc., 211 
Degenerative stigmata, 216 
Delinquency, 499 
‘‘ Délire chronique,” 346 
Delirium, epileptic, 360 
s hysterical, 241 
Pe tremens, 402 
4 rf chloral, 383, 407 
Delusions, 165 
SS in general paralysis, 439 
5 in melancholia, 272 
Dementia, alcoholic, 416 
Ps arteriopathic, 413 
ie epileptic, 362 
maniacal-depressive in- 
sanity, 299 
= paralytica, 431 
5 paranoides, 311, 338 
za precox.3i7 
Pi senile, 475 
Af syphilitic, 473 
Dendrons, 5 
Depressio apathetica, 275 
Depression, epileptic, 359 
Deprivation of senses, 494 
Determinism, 79, 85, 179 
Dial, 456 
Dialacetin, 369 
Digestive disturbances, 
284 
Dilatation of stomach, 239 
Dipsomania, 258 
Disappearances, mysterious, 361 
Disorders of association of ideas, 
140-1 
m of conduct, 152, 324 
x of emotion, 148 
* of instinct, 155 
- of memory, 141 
. of movement, 235 
~ of perception, 124 
ie of sensation, 188, 233 
. of sentiment, 170 
i of speech, 158 
a of vision, 120 
F of volition, 152 
Disorientation, 360, 391, 402, 406, 
44 
Dissociation, 230 
Distance, estimation of, 39 
Distractibility, 226 
Douche bath, 545 
Dreams, 99, 189, 270 
Drug habits, 371 
Dysentery in asylums, 524 


264, 280, 


588 MIND 


E 


Ears, deformities of, 213 
Eccentrics, 307 
Echolalia, 159, 325 
Echopraxia, 158, 324, 325 
Eclampsic idiocy, 502 
Ecmnesia, 241 
Edridge-Green’s colour theory, 21 
Ego, 112 
,, Changed, 172 
Ego-instincts, 75 
Egocentric paranoia, 308 
Emotional reaction defect, 150 
Ue, excess, 148 
Emotions, 57-8 
repressed, 63 
Encephalitis, chronic, 504 
os lethargica, 468 
End-bulbs, 25 
Endocrines, 419 
Endothelial cells, 582 
Ependymal granulation, 465, 479 
Epicritic sensation, 16 
Epidemic encephalitis, 468 
Epigastric sensation, 128 
Epilepsy, 349 
By minor, 357 
Epileptic fits in general paralysis, 
434 
» aure, 354 
7 automatism, 361 
- character, 351 


As confusion, 360 
2 convulsion, 355 
=: delirium, 360 

aS equivalents, 358 
Ae idiocy, 503 

a insanity, 350 


state, 358, 434 

Epiloia, 504 
Ereutophobia, 256 
Ergograph, 93 
Ergophobia, 227 
Erroneous instincts, 157 

Pr judgments, 165 

y localization, 123 
Erythrasma, 528 
Escape, 558 
Ether inebriety, 386 
Exhaustion, 92, 290 

ye insanity, 388 

physical basis of, 60 

Exophthalmic goitre, 246 
Eyes, anomalies of, 216 


F 
Facilitation, 8 
Faddists, 307 
Faradism, 281 


AND ITS DISORDERS 


Fatigue, 92 

Fear in exophthalmic goitre, 246 
Fears, irrepressible, 254 

Febrile attacks in general paralysis, 


435 
Fechner’s law, 19 
Feeble-minded, 557 
Feigned insanity, 518 
Fellatio, 196 
Felo-de-se, 565 
Fetichism, 196 — 
Fits, alcoholic, 411 

,, epileptic, 355 

,, general paralytic, 434 

,, hystero-epileptic, 236 
Fixation hysteria, 238 
Flexibilitas cerea, 324 
Flight of ideas, 141 
Focal symptoms, 464 
Folie a deux, 314 

,, de toucher, 158 
Food and feeding, 542 
Forehead wrinkling in dementia 

precox, 322 
in melancholia, 

266 


a”) a2 


Forgetting, 50 

Free association, 188 

Freud’s psychology, 176 

Fright, 203 

Frontal lesions, 464 

‘“ Funny-bone ”’ anesthesia, 438 
Furor, epileptic, 360 


Gastric dilatation, 209 
Gemmules, 6 
General paralysis, 431 

a ae juvenile, 447 

a treatment, 539 
Genetous idiocy, 501 
Genital sense, 121 

», hallucinations of, 134 

Glia cells, 458-9 
Globulin reaction, 583 
Globus hystericus, 128, 235 
““Glove’”’ anesthesia, 234 
Glycosuria, 491 
Goitre, exophthalmic, 246 
Gold-Sol test, 580 
Gout, 491 
Gustatisms, 129 
Gustatory contrasts, 27 

oe sensations, 26 


1s! 
Habit, 80 
Hematoma auris, 214 
Hematoporphyrinuria, 278, 354 
Hair in dementia pracox, 320 
», overgrowth of, 218, 529 


INDEX 589 
Hallucinations, 27 

def in delirium tremens, I 

135, 401 Ideation, 30 
Pi in exhaustion, 92, difficulty of, 139 

390 physical basis of, 30 
os of cold, 133 Ideational inertia, agnostic, 125-6, 
+ of pain, 133 392 
aA olfactory, 132 of », apraxia, 153,161, 
4 psychology of, 139 392, 475 
Fe sexual, 134 4 type, 44, 139 
hs tactile, 133 Ideomotor apraxia, 153 
A visceral, 134 Idiocy, 492 


warmth, 133 


Hands, ‘ deformities “of, 216, 317, 
319 
Handshake in dementia precox, 


329 
Bs in mania, 285 
in melancholia, 267 
Haschisch poisoning, 385 
Head injury, 467 
Hearing, 24, 121 
¥ defect of, 121, 438, 473 
Hebephrenia, 332 
Hemianesthesia, hysterical, 233 
Hemianopia, hysterical, 234 
Hemiplegia, hysterical, 237, 564 
Herd, 75-6 
Heredity, 199 
Homicidal impulse, 258 
-Homosexuality, 192 
Hormonal, 281 
Hospitals, registered, 551 
Houses, licensed, 550 
Huntington’s chorea, 485 
Hydrocephaly, 502 
Hydrotherapy, 545 
Hyperesthesia, 122, 225, 235, 287 
Hypermnesia, 146, 292, 497 
Hyperprosexia, 164 
Hyperpyrexia in general paralysis, 
452 
Hypertrichosis, 529 
Hypertrophic idiocy, 502 
Hypnosis, 101 
Hypnotics, 545 
Hypochondriacal melancholia, 274 
paranoia, 316 
Hypochondriasis, 310 
Hypothyroidism, treatment by, 282 
Hypotonia in anergic stupor, 296 
Hysteria, 230 
4 anxiety, 238 
* cataleptic, 237 
" conversion, 233 
hp fixation, 238 
Hysterical fits, 236 
ie insanity, 241 
4, monoplegia, 237 
An paraplegia, 237 
Hystero-epilepsy, 236 


Illegitimacy, 492 
Illusions, 127 
Fe of memory, 147 
fe of recognition, 147 
- psychology of, 139 
Imagination, 5 
Imbecility, 496 
“ moral, 499 
Imperception, 124, 390, 402, 406, 
412, 474, 481, 484 
+ physical basis of, 126 
Impulses, irrepressible, 257 
Impulsive action, 71 
Inaction, 80 
Incidence of insanity, 173, 194 
Incoherence, 159, 289 
Indian hemp, 385 
Inebriation, 398 
Inertia of attention, 87, 125, 161, 
163, 392, 475 
,, Of emotion, 59 
», Of ideation, 124, 153 
Infantile psychosexual trends, 183 
Inhibition, 180 
Injury to head, 467 
Inquisition as to lunacy, 556 
Insane and the law, 550 
““ Insane fingers,” 529 
Insight, 169 
Instinctive attention, 88 
diminution of, 
164 
“ language, 68, 109 
Instincts, 65 
x classification of, 72 
disorders of, 155, 262, 324, 


a? a? 


440 

Intellectual fatigue, 94 

an sentiments, 106 
Interactionist school, 4 
Intercranial pressure, 463 
Interest, 91, 164 
Intermittent insanity, 261, 302 
Interpretation of dreams, 189 
Intoxication, 388 
Intrapsychic ataxia, 332 
Intraspinal pressure, 581 
Inversion, sexual, 192 


Isopral, 547 


299 


Irrepressible fears and thoughts, 254 
” impulses, 257 


J 


Janet’s conception of hysteria, 230 
doo ESE 2 34. 

Jaw deformities, 216 

Joffroy’s sign, 439 

Judgments, 52 

Judicial inquisition as to lunacy, 556 

Justice’s order, 6 


K 
Katatonia, 334 
Katatoniac stupor, 335 
Kinesthetic equivalent, 30 
Kinetoplasm, 5 
Korssakow’s syndrome, 408 
Krause’s end-bulbs, 25 
Kultschitzky’s hematoxylin, 577 


L 
Language, 109 
. and the unconscious, III 
ys instinctive, 68, 109 
Law of regression, 143 
», Of relativity, 13 
», Weber-Fechner, 19 
Lead encephalopathy, 387 
Leave of absence, 558 
Legal aspects of insanity, 550 
», Capacities of the insane, 559 
», responsibilities of the insane, 
560, 561 
Lesbian love, 192 
Letters, 548 
Leucoderma, 529 
Licensed houses, 550 
Lichen planus, 533 
Local signs, 31, 38 
Locke’s experiment, 26 
Lumbar puncture, 580 
Luminal-sodium, 369 
Lunacy Commission, 550 
Lymphocytes, 582 


M 

Malarial treatment for 
paralysis, 451 

Malingering, 518 
Mania, 283 
Mania a potu, 399 
Maniacal-depressive psychosis, 260 
Maniacal form of general paralysis, 


general 


445 
# handshake, 285 
Mannerisms, 158, 327 
Marchi’s stain, 577 
Marriage, advisability of, 303 
ey incidence of insanity, 202 


MIND AND ITS DISORDERS 


Marriage, nullity of, 560 
Masochism, 194 
Massage, 281 
Mast-cells, 458 
Masturbation, 191, 209, 225, 547. 
Mattoids, 307 
Mechanical restraint, 542 
Meco-narceine, 380 
Medical certificate, 533 
Medicines, 545 
Medinal, 546 
Meissner’ S$ corpuscles, 25 
Melancholia, 263 
senile, 274-5 
Melancholiac handshake, 267 
as wrinkling, 266 
Memory, 50 
i apparatus, 48 
7 disorders of, 141 
iy illusions of, 147 
. image, 50 
Meningitis, aoe 
type, 44 
Mental deficiency, 492 
ns ” Act, 557 
», exhaustion, 388 
», hospitals, 551 
»  Yeflexes, 102 
Mentation, unity of, 117 
Microcephalic idiocy, 502 
Mind, 9 
Monakow’s bundle, 63 
Mongolian idiocy, 501 
Monoplegia, hysterical, 237 
Moods, 60 
Moral imbecility, 499 
Moral sentiments, 106 
Moria, 465 
Morons, 505 
Morphia, 547 
Morphinism, 376 
Motor apraxia, 153 
», ceactions, Si74 
» signs of mania, 285 
,, Of melancholia, 266 
Muscular fatigue, 93 
Mutism, hysterical, 238 
Mysophobia, 255 
Myxcedema, 419 


N 
Narcolepsy, 362 
Necrophilia, 197 
Negativism, 157, 323, 325, 337 
Neologism, 133, 345 
Neurasthenia, 224 
Neurin, 8 
Neuroglia in general paralysis, 458 
Neurokyme, 8 
Neuron theory, 7 
Neurosis, 219 


INDEX 


Nissl stain, 576 

»,» bodies; 5 
Noguchi test, 583 
Noises, 24 
Nonne-Apelt test, 583 
Noopsyche, 331 
Now-ness, feeling of, 43 
Nullity of marriage, 560 


O 


Obedience, automatic, 
330 
Obsessional neurosis, 252 
Occasionalism, 4 
Occupation, 276, 542 
ie delirium, 403 
Ocular signs of general paralysis, 
435-6 
Olfactisms, 129 
Olfactory sensations, 27 
Opisthotonos, 236 
Opium, 547 
» habit, 376 
Optic neuritis, 464 
Order, after inquisition, 556 
,, by acommissioner, 556 
», forms, 567-574 
»,  Justice’s, 554 
», Reception, summary, 555 
» Urgency, 555 
Organic insanities, 430 
Osmic acid stain, 577 
Oxy-di-morphine, 377 


158, 324, 


Er 
Pachymeningitis haemorrhagica in- 
terna, 455 
Pack, wet, 545 
Pain, hallucinations of, 133 
Pain-spots, 25 
Palate, deformities of, 215 
Pancreas, 429 
Pappenheim’s stain, 582 
Paresthesia, 123 
Paraldehyde, 278, 545 
Paraldehydism, 384 
Paralysis agitans, 486 
Paralysis of voluntary movement, 
154 

Paramnesia, 147, 406, 480 
Paranoia, 304 

i alcoholic, 415 

a cocaine, 382 
Paranoid dementia, 311, 338 
Paraphrenia, 311, 343 
Paraplegia, hysterical, 237 
Parathyroid, 429 
Parkinsonian syndrome, 470 
Passions, 60 - 
Pauper lunatics, 552, 555 


591 


Pederasty, 192 
Pellagra, 530 
Perception, 30 

v disorders of, 124 

» of space, 32 

» of time, 42 

- physical basis of, 31 
Periodic insanity, 262 
Perseveration, 125-6, 153, 392, 475 
Personal differences (ego), 115 
Personalities, changed, 172 
Petition, 553; form, 567 
Petit mal, 357 
Phobias, 254 
Phonisms, 129 
Phosphenes, 131 
Photisms, 129 
Photopsia, 127 
Phthisis in asylums, 521 
Physical stigmata, 211 
Pigmentary disturbances, 529 
Pineal, 428 
Pinna, deformities of, 213 
Pitch, musical, 25 
Pituitary, 426 
Plasma cells, 451 
Plumbism, 387 
Polymorphonuclear leucocytes, 582 
Polyneuritic psychosis, 408 
Porencephaly, 512 
Position, sense of, 28 
Prefrontal lobes, 79-80 
Presbyophrenia, 479 
Pressure, intracranial, 463 

e intraspinal, 581 

np of activity, 155 
Pressure-spots, 25 
Professions and insanity, 205 
Prohibition, 374 
Projection, 10, 293 
Prolonged bath, 545 
Protopathic sensation, 16 
Pseudodipsomania, 372 
Pseudographia, 159 
Pseudolalia, 329 
Pseudoparesis, alcoholic, 411 
Psychical determinism, 179 
Psycho-analysis, 176 
Psychomotor hallucinations, 134 
Psychoneurosis, 224 
Psychoses, 260 
Psychosexual trends, 183, 224 
Psychotic symptoms, 182 
Pupils in general paralysis, 435 
Pygmalionism, 197 
Pyromania, 258 
Pyronin methyl green, 582 


Q 


Querulant paranoia, 313 


592 


R 


Racial differences, 115 
Reaction experiment, 81 
Reaction-time, 160 
Reactions, 181 
Reasoning, 52 
Recapture, 588 
Reception Orders, 552 
Recognition, 49 
-F illusions of, 147 

Redintegration, 48 
Reflex action, 8, 65 

», attention, 90 

rH diminution of, 164 

Registered hospitals, 551 
Regression, law of, 13 
Religion and insanity, 204 
Repressed emotions, 63 
Repression, 179, 180 
Respiratory hallucinations, 135 
Responsibilities of the insane, 560 

et seq. 
Rest cure, 242 
Restraint, 542 
Retardation of thought, 140 
Retrograde amnesia, 143 
Rigidity, katatoniac, 321, 335 

Se melancholiac, 266 

Rods and cones, 21 
Ross-Jones test, 583 
Ruffini’s cylinders, 25 


S 
Sadism, 194 


Sapphism, 192 
Scavenger cells, 459, 482 
Schedules, 567 
Schizophrenia, 332 
Sclerotic idiocy, 505 
Scoptophilia, 195 
Seborrheea, 527 
Seclusion, 542 
Seclusiveness, 332 
Secondary sensations, 129 
Segmental anesthesia, 234 
Seizures in general paralysis, 434 
Sejunctive dementia, 332 
Senile brain, 478 
,,. dementia, 473 
,, melancholia, 274 
», writing, 163, 476 
Sensation, 13 
= disorders of, 118 
“a epigastric, 128 
ae visceral, 121 
Sense of movement and position, 28 
Sensory apraxia, 152 
Sentiments, 104 
ye disorders of, 170 
Serum Moebius, 250 
Sex and station, 173 


MIND AND ITS DISORDERS 


Sex abnormalities, 191 
», glands, 429 
Sexual development, 185 
5, differences ie 
;,  “@XCess, a5 
» hallucinations, 134 
» Jnstinci ares 
,, inversion, 192 
5° ~perversion, 0% 
theory, 183 
Shell- shock, 208, 231 
Shock, 203 
Simian hands, 216 
Simple dementia pracox, 332 
i, Manid, gor 
Single care, 551 
Skin affections, 218, 264, 527 
Sleep, 96 
,, theories of, 98 
Sleeping draughts, 545 
Sleepy sickness, 468 
Smell, 121 
», hallucinations of, 132 
Sodomy, 191-2 
Softening, cerebral, 467 
Soneryl, 546 
Soured milk, 280 
Space-perception, 40 
Speech, 10g 
,, disorders of, 158, 268, 441 
Spider cells, 548-9 
Spiritualism, 4 
Sidbchen cells, 458 
Staining methods, 575 
Stammering, 497 
Statement of particulars, 553 
Static sense, hallucinations of, 135 
», Space-perception, 40 
Status epilepticus, 370, 434, 446 
Stereotypy, 157, 329 
Stigmata, physical, 211 
“Stocking ’’ anesthesia, 234 
Strumpell’s case, II 
Strychnine in exhaustion, 396 
Stupor, anergic, 295 
- epileptic, 361 
- katatoniac, 335 
oP melancholiac, 273 
Stuttering, 497 
Sublimation, 180 
Suggestibility, 404, 442, 480 
Suggestion, 244 
Suicidal impulses, 258, 290 
Suicide, 281 
», legal aspects of, 565 
+, prevention of, 548 
Sulphonal, 546 
poisoning, 278 
Summary Reception Orders, 552, 555 
Superficial reflexes, 286 
Suprarenals, 428 


INDEX 


Survival of the unfit, 200 
Symbolism, 189 

Sympathetic insanity, 188 
Synesthesiz, 129 

Synapses, 7 

Synaptic resistance, 7 

Syphilis and general. paralysis, 431 
Syphilitic idiocy, 505 
Systematized anesthesia, 126 


it 


Tabes in general paralysis, 434 
Tactile hallucinations, 133 
Taste, 121 

», contrasts, 27 

he Geiect Of,°121 

» hallucinations, 132 

», sensations, 26 

ye the sense of, 121 
Telepathy, 17 
Temperaments, 60 
Terminal dementia, 299 
Testamentary capacity, 559 
Then-ness, feeling of, 43 
Thought, train of, 47 
Thoughts, irrepressible, 254 
Thymopsyche, 331 
Thymus, 429 
Thyroid, 419 
Thyroigenous insanity, 419 
Thyro-iodine, 420 
Tics, 236 
Tigroid substance, 5 
Timbre, 25 
Time-perception, 42 
Tolerance of alcohol, 400 
Tone of feeling, 54 
Torts, 561 
Touch-spots, 25 
Toxic insanity, 388 
Train of thought, 47 
Transfer, 588 
Transference, 189 
Traumatism, cranial, 467 
Tribadism, 192 
Tricks, 327 
Trional, 278, 547 
Trophoplasm, 5 
Tube feeding, 543 
Tubercular meningitis, 467 

veh peritonitis, 489 
Tumours, cerebral, 464 . 


U 


Unconscious, the, 179 
action, 84 

63 associations, 52 
+ attention, 90 


>” 


593 


Unconscious emotion, 63 
st mentation, II 
fi: percepts, 45 
‘ sensations, 28 
Ulcerative colitis, 524 
Ulnar anesthesia, 438 
Unity of ideation, 33, 129, 168 
», Of mentation, 117 
Uremia, 490 
Urgency Order, 555; form, 569 
Urine in delirium tremens, 404 
», in epilepsy, 364 
», in mania, 284 
», in melancholia, 265 
Urnings, 192 
Urticaria, 531 


Valerian, 232 
Verbigeration, 158, 330 
Verbochromia, 129 
Veronal, 279, 546 
Visceral hallucinations, 134 
sensations, I2I 
Visceroptosis, 239 
Vision, 20 
» diminution of, 120 
», hallucinations of, 131 
Visits from friends, 548 
Visual space-perception, 33 


| Vitiligo, 529 


Volition, defect of, 226 
Voluntary action, 78 
ay attention, 88 
nA boarders, 552 
Voyeurs, 190 


W 


| Wandering lunatics, 552, 555 


War and insanity, 208, 231 
Warm-spots, 26 
Warmth, hallucinations of, 133 
Warning in epilepsy, 354 
Wassermann reaction, 585 
Weaning from chloral, 383 
from cocaine, 382 

ne from morphia, 397 
Weber’s law, 19 
Weigert-Pal stain, 577 
Weigert’s stain for neuroglia, 578 
Weir Mitchell treatment, 242 
Wet pack, 545 
Wig collectors, 196 
Witnesses, insane aS, 559 
Witselsucht, 405 
Wrinkling in dementia precox, 322 

az in melancholia, 266 

Writing of the insane, 159, 268, 392, 


412, 443, 476 


>”? 


H. K. LEWIS & CO. LTD., 28, GOWER PLACE, LONDON 


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